Inertia suppresses signatures of activity of active Brownian particles in a harmonic potential

A harmonically trapped active Brownian particle exhibits two types of positional distributions-one has a single peak and the other has a single well-that signify steady-state dynamics with low and high activity, respectively. Adding inertia to the translational motion preserves this strict classification of either single-peak or single-well densities but shifts the dividing boundary between the states in the parameter space. We characterize this shift for the dynamics in one spatial dimension using the static Fokker-Planck equation for the full joint distribution of the state space. We derive local results analytically with a perturbation method for a small rotational velocity and then extend them globally with a numerical approach.

Comparative 16S rRNA gene sequencing study of subgingival microbiota of healthy subjects and patients with periodontitis from four different countries

AIM

To investigate the differences between the subgingival microbiota of healthy subjects (HS) and periodontitis patients (PP) from four different countries through a metagenomic approach.

MATERIALS AND METHODS

Subgingival samples were obtained from subjects from four different countries. Microbial composition was analysed through high-throughput sequencing of the V3-V4 region of the 16S rRNA gene. The country of origin, diagnosis and clinical and demographic variables of the subjects were used to analyse the microbial profiles.

RESULTS

In total, 506 subgingival samples were analysed: 196 from HS and 310 from patients with periodontitis. Differences in richness, diversity and microbial composition were observed when comparing samples pertaining to different countries of origin and different subject diagnoses. Clinical variables, such as bleeding on probing, did not significantly affect the bacterial composition of the samples. A highly conserved core of microbiota associated with periodontitis was detected, while the microbiota associated with periodontally HS was much more diverse.

CONCLUSIONS

Periodontal diagnosis of the subjects was the main variable explaining the composition of the microbiota in the subgingival niche. Nevertheless, the country of origin also had a significant impact on the microbiota and is therefore an important factor to consider when describing subgingival bacterial communities.

Determinantes de la inseguridad alimentaria y su asociación con prácticas de alimentación y lactancia materna en el primer año de vida

OBJETIVO

analizar los determinantes de la Inseguridad Alimentaria (IA) y su relación con las Prácticas de Alimentación (PA) y las Prácticas de Lactancia Materna (PLM) en el primer año de vida.

MÉTODOS

análisis de tipo cuantitativo sobre el binomio madre-hijo de una cohorte en México. Los datos de interés fueron el estado de seguridad alimentaria (SA), las PA y las PLM. Se desarrolló un modelo de regresión para evaluar determinantes asociados a la IA y un análisis de medias para determinar el impacto de la IA en las PA y las PLM.

RESULTADOS

el 54.1% de hogares presentó algún grado de IA. Las madres con pareja (OR = 0.25; p = 0.05) y con escolaridad superior (OR = 0.50; p = 0.04) tuvieron menor riesgo de padecer IA. En contraste, los hogares con mujeres mayores de 25 años estuvieron más expuestos a la IA (OR = 3.0; p = 0.00). Los hogares con IA introducen alimentos no recomendados como dulces, galletas o pastelitos (p = 0.00) y bebidas no lácteas azucaradas (p = 0.05) de forma prematura.Conclusiones:la IA requiere mayor atención por sus efectos en las PA y las PLM, las cuales son consideradas como factores asociados al desarrollo de mala nutrición.

Heterogeneity in effective size across the genome: effects on the inverse instantaneous coalescence rate (IICR) and implications for demographic inference under linked selection

The relative contribution of selection and neutrality in shaping species genetic diversity is one of the most central and controversial questions in evolutionary theory. Genomic data provide growing evidence that linked selection, i.e. the modification of genetic diversity at neutral sites through linkage with selected sites, might be pervasive over the genome. Several studies proposed that linked selection could be modeled as first approximation by a local reduction (e.g. purifying selection, selective sweeps) or increase (e.g. balancing selection) of effective population size (Ne). At the genome-wide scale, this leads to variations of Ne from one region to another, reflecting the heterogeneity of selective constraints and recombination rates between regions. We investigate here the consequences of such genomic variations of Ne on the genome-wide distribution of coalescence times. The underlying motivation concerns the impact of linked selection on demographic inference, because the distribution of coalescence times is at the heart of several important demographic inference approaches. Using the concept of inverse instantaneous coalescence rate, we demonstrate that in a panmictic population, linked selection always results in a spurious apparent decrease of Ne along time. Balancing selection has a particularly large effect, even when it concerns a very small part of the genome. We also study more general models including genuine population size changes, population structure or transient selection and find that the effect of linked selection can be significantly reduced by that of population structure. The models and conclusions presented here are also relevant to the study of other biological processes generating apparent variations of Ne along the genome.

Breastfeeding and feeding practices in the first year of life and its association with overweight and obesity of children in Mexico

Abstract Objectives: to evaluate feeding practices in the first year of life and their association with the development of overweight and obesity in children in Mexico. Methods: the association between overweight and obesity with different feeding practices were evaluated. The data was processed using the statistical package Stata version 14 using logistic regression models. Results: 396 children were evaluated; the prevalence of overweight and obesity was 6% and 7.7% presented a possible risk of overweight. 6.9% had exclusive breastfeeding in the first 6 months of life and 71.7% were fed infant formula. The variables significantly associated with the development of overweight and obesity in the first year of life were the age of the child (p =0.043, RR=0.57), the introduction of fluids in the first three days of life (p=0.02, RR=2.90), consumption of foods with a high sugar content (p =0.01, RR=0.25), consumption of milk other than breast (p =0.02, RR3.25) and egg consumption (p =0.05; RR=0.28). Conclusions: our results show that it is essential to attend complementary feeding practices and reinforce exclusive breastfeeding in the first year of life, as measures to prevent overweight and obesity to improve health in childhood.

DHA Supplementation of Obese Rats throughout Pregnancy and Lactation Modifies Milk Composition and Anxiety Behavior of Offspring

We investigated if supplementing obese mothers (MO) with docosahexaenoic acid (DHA) improves milk long-chain polyunsaturated fatty acid (LCPUFA) composition and offspring anxiety behavior. From weaning throughout pregnancy and lactation, female Wistar rats ate chow (C) or a high-fat diet (MO). One month before mating and through lactation, half the mothers received 400 mg DHA kg⁻¹ d⁻¹ orally (C+DHA or MO+DHA). Offspring ate C after weaning. Maternal weight, total body fat, milk hormones, and milk nutrient composition were determined. Pups’ milk nutrient intake was evaluated, and behavioral anxiety tests were conducted. MO exhibited increased weight and total fat, and higher milk corticosterone, leptin, linoleic, and arachidonic acid (AA) concentrations, and less DHA content. MO male and female offspring had higher ω-6/ ω-3 milk consumption ratios. In the elevated plus maze, female but not male MO offspring exhibited more anxiety. MO+DHA mothers exhibited lower weight, total fat, milk leptin, and AA concentrations, and enhanced milk DHA. MO+DHA offspring had a lower ω-6/ω-3 milk intake ratio and reduced anxiety vs. MO. DHA content was greater in C+DHA milk vs. C. Supplementing MO mothers with DHA improves milk composition, especially LCPUFA content and ω-6/ω-3 ratio reducing offspring anxiety in a sex-dependent manner.

Impact of model assumptions on demographic inferences: the case study of two sympatric mouse lemurs in northwestern Madagascar

BACKGROUND

Quaternary climate fluctuations have been acknowledged as major drivers of the geographical distribution of the extraordinary biodiversity observed in tropical biomes, including Madagascar. The main existing framework for Pleistocene Malagasy diversification assumes that forest cover was strongly shaped by warmer Interglacials (leading to forest expansion) and by cooler and arid glacials (leading to forest contraction), but predictions derived from this scenario for forest-dwelling animals have rarely been tested with genomic datasets.

RESULTS

We generated genomic data and applied three complementary demographic approaches (Stairway Plot, PSMC and IICR-simulations) to infer population size and connectivity changes for two forest-dependent primate species (Microcebus murinus and M. ravelobensis) in northwestern Madagascar. The analyses suggested major demographic changes in both species that could be interpreted in two ways, depending on underlying model assumptions (i.e., panmixia or population structure). Under panmixia, the two species exhibited larger population sizes across the Last Glacial Maximum (LGM) and towards the African Humid Period (AHP). This peak was followed by a population decline in M. ravelobensis until the present, while M. murinus may have experienced a second population expansion that was followed by a sharp decline starting 3000 years ago. In contrast, simulations under population structure suggested decreasing population connectivity between the Last Interglacial and the LGM for both species, but increased connectivity during the AHP exclusively for M. murinus.

CONCLUSION

Our study shows that closely related species may differ in their responses to climatic events. Assuming that Pleistocene climatic conditions in the lowlands were similar to those in the Malagasy highlands, some demographic dynamics would be better explained by changes in population connectivity than in population size. However, changes in connectivity alone cannot be easily reconciled with a founder effect that was shown for M. murinus during its colonization of the northwestern Madagascar in the late Pleistocene. To decide between the two alternative models, more knowledge about historic forest dynamics in lowland habitats is necessary. Altogether, our study stresses that demographic inferences strongly depend on the underlying model assumptions. Final conclusions should therefore be based on a comparative evaluation of multiple approaches.

Pre-exposure prophylaxis and its implications in Mexico: notions of men who have sex with men

Background The aim of this study was to analyse ideas regarding pre-exposure prophylaxis (PrEP) for the prevention of HIV among groups of men who have sex with men in Mexico for future implementation in health services.

METHODS

During 2015, 54 people participated in four focus groups in three Mexican cities. Issues related to challenges for uses and limitations of PrEP were explored.

RESULTS

In contrast with other qualitative studies, which emphasised problems with relationships with other people for PrEP use or access to key populations, Mexican participants focused their concerns around the public health services organisation: PrEP is too expensive and the health services have no resources, which will affect services and result in discrimination. Participants identified possible stigmatisation related to prejudices of medical providers who do not approve the decreased use of condoms. As a potential solution, participants suggested that the Mexican Government could negotiate a lower cost for PrEP and public health services could provide the medication, with periodical review of the arrangements by civil organisations.

CONCLUSION

In the current context of the new Mexican government, it is necessary to propose public politics focused on negotiating with pharmaceutical companies on the costs of the PrEP, coordinating public services with groups within civil society and strengthening policies and actions to reduce stigma and discrimination.

Undiagnosed Hypertension: Evidence and Suggestions for Greater Health Coverage of Vulnerable Groups

Access to health services for low-income families continues to be one of the greatest challenges for health systems globally. The coverage extension strategies developed in recent years precisely try to respond to the health needs of families or patients who do not have private health insurance. In the case of non-communicable disease problems such as undiagnosed hypertension, it is particularly relevant to guarantee greater access for detection, prevention and treatment. The first part of this manuscript highlights the relevance of recently reported quantitative evidence on the effects of ACA Medicaid on the prevalence rates of undiagnosed hypertension and of patients without antihypertensive medication. The second part emphasizes the need to develop a comprehensive analysis that includes evidence from quantitative and qualitative analysis for a better measurement of the problem under study.

Gobernanza en el sistema de salud ante la pandemia por Covid-19 en México

Objetivo. Analizar la gobernanza en el sistema de salud en México, en las políticas frente a la pandemia por Covid-19. Material y métodos. Estudio cualitativo, analítico, realizado entre junio y noviembre de 2020. Se analizaron 41 entrevistas semiestructuradas que se aplicaron a acto-res clave del sistema de salud y que se organizaron en el software ATLAS.ti 9. El análisis se adhirió a los principios teórico-metodológicos del Marco Analítico de Gobernanza. Resultados. El problema: la formulación de políticas fue centralizada; los actores: sólo los altos mandos participan en las decisiones; las normas: los valores sociales y el liderazgo determinan su nivel de responsabilidad; toma de decisio-nes: los altos mandos reconocieron poder para proponer modificaciones al Marco Normativo; los nodos: las políticas federales fueron adaptadas a nivel estatal de manera diferen-ciada. Conclusiones. La gobernanza centralizada, los niveles diferenciados de convocatoria de los actores, su poder de decisión, acuerdos, responsabilidad y liderazgo, definieron el alcance de la gobernanza y, a su vez, el nivel de respuesta ante la pandemia por Covid-19.

Recent trends for the management of diabetes for older adults in the context of universal coverage and COVID-19: evidence from Mexico

Background

To identify trends in the epidemiological and economic burden of diabetes in the elderly.

Methods

Using the Box–Jenkins method to estimate expected cases for the period 2020–2022, costs were determined with the instrumentation technique. The population base was 4 032 189 older adults diagnosed with diabetes in 2019.

Results

Regarding the epidemiological burden, there is an increase of 11–15% (p<0.001). Comparing the economic burden for 2020 vs 2022, the increase is estimated as 29% (p<0.05).

Conclusion

In the framework of the coronavirus disease 2019 pandemic, the increase in diabetes cases and costs in older adults substantially complicates the scope of universal coverage for patients with diabetes.

Adult rats from undernourished dams show sex-dependent impaired expression in taste papillae and hypothalamus of genes responsible for sweet and fat detection and signalling

AIM

Individuals undernourished in utero or during early life are at high risk of developing obesity and metabolic disorders and show an increased preference for consuming sugary and fatty food. This study aimed at determining whether impaired taste detection and signalling in the lingual epithelium and the brain might contribute to this altered pattern of food intake.

METHODS

The preference for feeding fat and sweet food and the expression in circumvallate papillae and hypothalamus of genes coding for sweet and fat receptors and transducing pathways were evaluated in adult rats born to control or calorie-restricted dams. Expression in the hypothalamus and the brain's reward system of genes involved in the homeostatic and hedonic control of food intake was also determined.

RESULTS

Male and female undernourished animals exhibited increased expression in taste papillae and hypothalamus of T1R1, T1R2, CD36, gustducin, TRMP5 and PLC-β2 genes, all of which modulate sweet and fat detection and intracellular signalling. However, the severity of the effect was greater in females than in males. Moreover, male, but not female, undernourished rats consumed more standard and sweetened food than their control counterparts and presented increased hypothalamic AgRP and NPY mRNAs levels together with enhanced dopamine transporter and dopamine receptor D2 expression in the ventral tegmental area.

CONCLUSIONS

Maternal undernutrition induces sex-specific changes in food preferences and gene expression in taste papillae, hypothalamus and brain reward regions. The gene expression alterations in the male offspring are in line with their preference for consuming sugary and fatty food.

Inferring number of populations and changes in connectivity under the n-island model

Inferring the demographic history of species is one of the greatest challenges in populations genetics. This history is often represented as a history of size changes, ignoring population structure. Alternatively, when structure is assumed, it is defined a priori as a population tree and not inferred. Here we propose a framework based on the IICR (Inverse Instantaneous Coalescence Rate). The IICR can be estimated for a single diploid individual using the PSMC method of Li and Durbin (2011). For an isolated panmictic population, the IICR matches the population size history, and this is how the PSMC outputs are generally interpreted. However, it is increasingly acknowledged that the IICR is a function of the demographic model and sampling scheme with limited connection to population size changes. Our method fits observed IICR curves of diploid individuals with IICR curves obtained under piecewise stationary symmetrical island models. In our models we assume a fixed number of time periods during which gene flow is constant, but gene flow is allowed to change between time periods. We infer the number of islands, their sizes, the periods at which connectivity changes and the corresponding rates of connectivity. Validation with simulated data showed that the method can accurately recover most of the scenario parameters. Our application to a set of five human PSMCs yielded demographic histories that are in agreement with previous studies using similar methods and with recent research suggesting ancient human structure. They are in contrast with the view of human evolution consisting of one ancestral population branching into three large continental and panmictic populations with varying degrees of connectivity and no population structure within each continent.

Family History of Psychiatric Disorders and Clinical Factors Associated With a Schizophrenia Diagnosis

Background

Schizophrenia (SCH) and bipolar disorder (BD) have both shared and unique genetic risk factors and clinical characteristics. The aim of the present study was to identify potential risk factors significantly associated with SCH, relative to a BD reference group.

Methods

Data were obtained from medical records of patients that entered a major Mexico City hospital during 2009–2010 presenting psychotic symptoms (n = 1132; 830 cases of SCH, 302 cases of BD; 714 men and 418 women). SCH and BD diagnoses were compared with respect to a number of family and clinical characteristics. Logistic and linear regression analyses were used to respectively identify factors selectively associated with the SCH diagnosis relative to the BD diagnosis and explore the relationship between PANSS scores and parental age at time of birth to the age of SCH onset.

Results

Patients with SCH showed greater functional impairment than those with BD. Family history of mental illness, premorbid schizoid-like personality, and obstetric trauma were significantly associated with the SCH diagnosis. The association of obstetric trauma with SCH was greatest in male patients with a family history of mental illness. In women, increased paternal and decreased maternal age at time of the patient’s birth were associated with an earlier age of SCH onset.

Conclusion

Male gender, showing premorbid schizoid-like personality, familial SCH, and obstetric trauma are risk factors that distinguish SCH from BD. Additionally, our results suggest that risk for SCH relative to BD may be importantly influenced by interactions between familial risk, gender, and obstetric trauma.

Recent trends for the management of hypertension in older adults in Latin America in the context of universal coverage: Evidence from Mexico

Taking the Mexican case as a tracer of what is happening in Latin America on public health, we estimate the recent changes and challenges for the management of hypertension in older adults in the context of universal health coverage. The population base was 200, and 308 reported cases of older adults with hypertension. The cost-evaluation method used was based on the instrumentation and consensus technique. Regarding epidemiological changes for 2016 versus 2018, there is an increase of 21% (CI: 95%, p < 0.001). Comparing the economic impact in 2016 versus 2018 (CI: 95%, p < 0.001), the increase is 33%. The total amount estimated for hypertension in 2018 (in US dollars) was $ 1,896,520,273. It includes $ 898,064,979 as direct costs and $ 998,455,294 as indirect costs. The recent trends show that the financial requirements for the coming years do not guarantee the effectiveness of the coverage rates required for the elderly. In terms of catastrophic expenditure, the challenge is not minor, the greatest economic burden is for the pocket of patients and their families.

Social determinants of overweight and obesity in the mother-child binomial: evidences from Mexico

Background

To analyze the influence of socioeconomic determinants on the development of overweight and obesity in the mother-child binomial.

Methods

This is a study based on a prospective cohort of the mother-child binomial. Using STATA software, the association between the mothers’ body mass index and the nutritional status of minors was analyzed using a logistic regression model with socioeconomic and demographic variables.

Results

The combined prevalence of overweight and obesity in cohort mothers was 53.2%. A statistically significant association was found between the overweight mothers and minors with possible risk of overweight (p 0.001) and with overweight (p 0.001). The logistic regression model was adjusted by age and marital status and linked maternal overweight and obesity with the following variables: severe food insecurity (RR 1.17, CI 0.04–0.31), having a health problem (RR 1.5, CI 0.86–2.05), income (RR 1.79, CI .49–1.30), smoking (RR 1.1, CI 0.80–1.37) and dietary pattern (RR 1.5, CI 0.38–0.87).

Conclusions

The study highlights the importance of paying attention to risk factors starting at the gestational stage, since at this time the mother’s nutritional status has an influence on the offspring’s growth and development. Evidences exist of an association between intergenerational transmission of obesity and socioeconomic aspects of the mother. These evidences must be considered in the revision and adjustments to health system interventions for the prevention of obesity in the mother-child binomial.

[Implementation research of primary health care in Paraguay in three periods of government: political, technical and social dimensions at the subnational level.]

OBJECTIVE

The study hopes to contribute to the analysis of political, technical and social dimensions and sub-dimensions that affect the processes of adjustments to the health system model based on the renewed PHC (Primary Health Care) strategy, at the regional (meso) and local levels. (micro), levels where problems and obstacles are externalized and institutional capacity gaps are verified, in contexts of changes in political leadership, which put their sustainability at risk. The observation included three government periods (2008-2012, 2012- 2013 and 2013-2018), in two departments of Paraguay (Misiones -rural- and Central -urban-).

METHODS

Qualitative research on the implementation of public health policy in Paraguay, aimed at promoting improvements in health services in specific contexts, through case studies, complemented with a documentary review. It explores macro, meso, and micro health processes, disaggregated in their political, social, and technical dimensions, to trace the PHC management profile over time. Directors, managers, and professionals in the field of health with experience, commitment, adherence, and prior knowledge were interviewed, using a priori analysis categories. The data and selection of discursive fragments were processed with the Atlas Ti software and auxiliary matrices in Excel.

RESULTS

Social changes and health outcomes are perceived in the study regions, despite financial restrictions and no flexibility of public spending on health attributed to the leadership and individual performance of health workers, which establish differences in terms of empowerment, cohesion and commitment in the development of the strategies outlined by the technical teams and decision-makers responsible for the implementation of policy lines in primary health care.

CONCLUSIONS

There are technological limitations, asymmetries of the information subsystems that translate into management weaknesses, as well as little community participation in the design and evaluation of health plans. Coordination weaknesses and improvement plans were detected in operating units of the regional networks, as well as. different training modalities. The availability of specialists in family medicine is low.

Evidencias y tendencias para tomar decisiones sobre medidas de contención y mitigación de Covid-19 en Jalisco, México

No disponible

Barriers and Facilitators in Timely Detection of Chronic Kidney Disease: Evidences for Decision-Makers

Chronic Kidney Disease (CKD) is classified, according to the glomerular filtratation rate. Timely diagnosis during the first three stages represents a lower expenditure for health systems in the treatment of this disease. Thus, this study intends to identify barriers and facilitators in timely detection of CKD, from the perspective of healthcare providers. This is an exploratory study of the qualitative type. A mapping of the literature was carried out in order to develop the following topics: perceptions of the implications of CKD for the health system at an international level and in Mexico, as well as experience related to barriers and facilitators in timely CKD detection in Mexico. Based on the identified topics, semi-structured interviews were carried out with decision-makers, operational personnel, civil and academic associations representatives in Mexico City and Cuernavaca, Morelos. The main identified barriers were: system fragmentation; overload of services at first and second levels of care; insufficient human resources; lack of updating of the clinical practice guide and scarce training. With respect to facilitators, we found there are civil society actions. Finally, requirements for timely detection of CKD are consistent with what is described in the international guides. The identification of barriers and facilitators in timely CKD detection gives us an outlook of the problem in Mexico and leads to proposals for action. The development of a national program with a strategy for timely detection of CKD may help unify inter-institutional criteria considering the protocols for clinical practice that take into account each institution's organization and resources.

Barreras y facilitadores para una alimentación saludable y actividad física en mujeres embarazadas con sobrepeso y obesidad

Objetivo:

identificar barreras y facilitadores sobre dieta saludable y actividad física en mujeres embarazadas con sobrepeso y obesidad que viven en entornos de vulnerabilidad social y económica, destacando determinantes socioeconómicos y culturales.

Metodología:

estudio cualitativo longitudinal, donde las entrevistadas corresponden a mujeres embarazadas seleccionadas de una cohorte prospectiva en México. Se aplicó una guía semiestructurada de entrevista que exploró barreras y facilitadores para llevar una dieta saludable y poder realizar actividad física. Las entrevistas se transcribieron y codificaron en Atlas Ti, generando 23 códigos temáticos.

Resultados:

existen barreras y facilitadores contextuales y sociales que predisponen un mayor riesgo de padecer sobrepeso y obesidad durante el embarazo. Destacan conocimientos limitados sobre una dieta saludable, condiciones de vulnerabilidad social, así como un sentido de fragilidad en las mujeres que incrementa su sedentarismo.

Conclusiones:

en el diseño e implementación de intervenciones en promoción de la salud es fundamental considerar las barreras y facilitadores culturales y socioeconómicas sobre alimentación saludable y actividad física durante el embarazo, para desarrollar intervenciones de salud pública que favorezcan una mayor prevención de sobrepeso y obesidad en mujeres embarazadas.

[Socioeconomic determinants of maternal obesity in Mexico and France. Comparative analysis of two cohorts]

OBJECTIVE

To identify and analyze the socioeconomic indicators of maternal obesity in Mexico and France.

MATERIAL AND METHODS

Comparative study of two cohorts: EDEN (France) and NUTTSEA (Mexico). The study population consisted of women who requested prenatal consultation at week 24 of pregnancy. Data were collected using questionnaires and semi-structured interviews. The variables of interest were socioeconomic aspects, nutrition, anthropometry and food security. The quantitative analysis was performed using Stata and the qualitative analysis with Atlas-ti.

RESULTS

In the EDEN cohort, 68.6% were aged 25-34 years, 73% had paid employment and 53% completed high school. In addition, 6.6% reported having difficulty accessing food and the mean gestational BMI was 23.23 ± 4.6. In the NUTTSEA cohort, 55% were in the age range 18-24 years, 15% reported having paid employment, 42% had completed secondary education, 32.1% presented a degree of food insecurity, and the mean BMI was 27.8 ± 4.8.

CONCLUSIONS

The qualitative and quantitative results of both cohorts suggest that populations with greater socio-economic vulnerability are more prone to maternal obesity, which leads to determine guidelines on barriers and facilitators to strengthen programs to prevent it maternal obesity.

Challenges and dilemmas on universal coverage for non-communicable diseases in middle-income countries: evidence and lessons from Mexico

BACKGROUND

Despite more than 20 years of reform projects in health systems, the universal coverage strategy has not reached the expected results in most middle-income countries (MICs). Using evidence from the Mexican case on diabetes and hypertension as tracers of non-communicable diseases, the effective coverage rate barely surpasses half of the expected goals necessary to meet the challenges that these two diseases represent at the population level. Prevalence and incidence rates do not diminish either; they even grow. In terms of the economic burden, this means that lack of financial protection and catastrophic expense rates have increased, contrary to what could have been expected.

DISCUSSION

As any complex system, health systems present challenges and dilemmas that are difficult to solve. In terms of universal coverage, when contrasting normative coverage versus effective coverage, the epidemiological, cultural, organizational and economic challenges and barriers become evident. Such challenges have not allowed a greater effectiveness of the contributions of state of the art medicine in the resolution of health problems, particularly in relation to diabetes and hypertension.

CONCLUSIONS

Despite of the existence of many universal coverage projects, strategies and programs implemented in MICs, challenges remain and, far from disappearing, unresolved problems are still present, even with increasing trends. The model of care based on a curative biomedical approach was enough to respond to the health needs of the last century, but is no longer adapted to the needs of the present century. The dilemmas of continuity vs. rupture require to review and discuss the background and structure of health systems and their underlying models of care. These two elements have not allowed the different coverage schemes to guarantee greater effectiveness in the application of state of the art medicine, nor a greater health care financial protection for patients and their families. We thus can either accept the fragmented health systems and bio-medical-curative models of care approach or, instead, we can move towards integrated health systems that would be based on a socio-medical-preventive approach to health care.

Trends and challenges in diabetes for middle-income countries: Evidence from Mexico

The epidemiological and economic burden of diabetes poses one of the main challenges for health systems worldwide. This is particularly relevant in middle-income countries because of the constant growing trends that have been observed in recent years. In order to identify trends and challenges on epidemiological and economic burden from diabetes in a middle-income country we developed a longitudinal analysis on costs and trends in the number of cases of diabetes in Mexico. The study population included total annual cases of diabetes at national level. Regarding the annual cumulative incidence for 2016 versus 2018, depending on the institution there is an increase of 9-13% (p < 0.001). Comparing the economic burden from incidence in 2016 versus 2018 (p < 0.05), there is a 26% increase. The total amount for diabetes in 2017 (US dollars) was $9,684,780,574. It includes $ 4,292,085,964 in direct costs and $ 5,392,694,610 in indirect costs. The total direct costs are: $ 510,986,406 for uninsured population; $ 1,416,132,058 for insured population; $ 2,235,969,330 for users' pockets. This is an example of what is happening in the management of diabetes care in middle-income countries and we suggest review and rethinking strategies of prevention, planning, organisation and resource allocation.

Challenges of health services related to the population displaced by violence in Mexico

OBJECTIVE

To analyze the impacts of the care to the population displaced by violence on the health system and the challenges that this entails.

METHODS

This is a narrative review of the national and international literature in PubMed, SciELO, WHO/PAHO, and Bireme. Inclusion criteria were date of publication (from 2000), relation with the subject, and language (Spanish or English). We found 292 documents, of which 91 met the inclusion criteria.

RESULTS

The main challenges are the intersectoral, participatory, and integral approach (with emphasis on mental health and sexual and reproductive health), ensured accessibility to health services, the need for a reliable registration and information system of the population displaced by violence and its characteristics, and the addressing of the biopsychosocial problems of the different groups, especially women, persons with disabilities or infectious diseases, adolescents, children, ethnic minorities, older adults and the lesbian, gay, bisexual, transsexual, and intersexual population.

CONCLUSIONS

The lack of political will to accept and see the internal displacement by violence and its importance as a humanitarian and public health problem is an obstacle to the adequate and timely care of the population displaced by violence in Mexico.

Stewardship and governance: structuring dimensions for Implementation Primary Health Care Policies in Paraguay, 2008-2017

This study analyzes the conduction patterns of implementing Primary Health Care (PHC) in Paraguay in three government periods (2008-2012, 2012-2013 and 2013-2017) and three management levels (national, regional and local). This is a qualitative study based on grounded theory. A priori categories on PHC stewardship and governance in Paraguay were analyzed. An open-ended questionnaire was applied to a sample of social, political and technical stakeholders: ministers, coordinators, managers, consultants, and international organizations' experts. Data were processed combining the use of Atlas Ti software and sorting findings in a structured Excel matrix. Gaps in leadership, regulatory mechanisms, technical capacities for health planning and management and financial implementation methods have affected PHC continuous expansion and strengthening process. The findings show limitations and possibilities for the implementation of this health policy in Paraguay, evidencing the need for greater qualification of management and political stability in its conduction.

The cost of diabetes in Latin America and the Caribbean in 2015: Evidence for decision and policy makers

BACKGROUND

The financial implications of the increase in the prevalence of diabetes in middle–income countries represents one of the main challenges to health system financing and to the society as a whole. The objective of this study was to estimate the economic cost of diabetes in Latin America and the Caribbean (LAC) in 2015.

METHODS

The study used a prevalence–based approach to estimate the direct and indirect costs related to diabetes in 29 LAC countries in 2015. Direct costs included health care expenditures such as medications (insulin and oral hypoglycemic agents), tests, consultations, hospitalizations, emergency visits and treating complications. Two different scenarios (S1 and S2) were used to analyze direct cost. S1 assumed conservative estimates while S2 assumed broader coverage of medication and services. Indirect costs included lost resources due to premature mortality, temporary and permanent disabilities.

RESULTS

In 2015 over 41 million adults (20 years of age and more) were estimated to have Diabetes Mellitus in LAC. The total indirect cost attributed to Diabetes was US$ 57.1 billion, of which US$ 27.5 billion was due to premature mortality, US$16.2 billion to permanent disability, and US$ 13.3 billion to temporary disability. The total direct cost was estimated between US$ 45 and US$ 66 billion, of which the highest estimated cost was due to treatment of complications (US$ 1 616 to US$ 26 billion). Other estimates indicated the cost of insulin between US$ 6 and US$ 11 billion; oral medication US$ 4 to US$ 6 billion; consultations between US$ 5 and US$ 6 billion; hospitalization US$ 10 billion; emergency visits US$ 1 billion; test and laboratory exams between US$ 1 and US$ 3 million. The total cost of diabetes in 2015 in LAC was estimated to be between US$ 102 and US$ 123 billion. On average, the annual cost of treating one case of diabetes mellitus (DM) in LAC was estimated between US$ 1088 and US$ 1818. Per capita National Health Expenditures averaged US$ 1061 in LAC.

CONCLUSIONS

Diabetes represented a major economic burden to the countries of Latin America and the Caribbean in 2015. The estimates presented here are key information for decision–making that can be used in the formulation of policies and programs to achieve greater efficiency and effectiveness in the use of resources for diabetes prevention in the 29 countries of LAC.

Challenges on the epidemiological and economic burden of diabetes and hypertension in Mexico

OBJECTIVE

To analyze the epidemiological and economic burden of the health services demand due to diabetes and hypertension in Mexico.

METHODS

Evaluation study based on a time series study that had as a universe of study the assured and uninsured population that demands health services from the three main institutions of the Health System in Mexico: The Health Department, the Mexican Institute of Social Security, and Institute of Services and Social Security for State Workers. The financing method was based on instrumentation and consensus techniques for medium case management. In order to estimate the epidemiological changes and financial requirements, a time series of observed cases for diabetes and hypertension 1994–2013 was integrated. Probabilistic models were developed based on the Box-Jenkins technique for the period of 2013–2018 with 95% confidence intervals and p < 0.05.

RESULTS

Comparing results from 2013 versus 2018, in the five regions, different incremental trends of 14%–17% in epidemiological changes and 58%-66% in the economic burden for both diseases were observed.

CONCLUSIONS

If the risk factors and the different models of care remained as they currently are in the three institutions analyzed, the financial consequences would be of greater impact for the Mexican Institute of Social Security, following in order of importance the Institute of Services and Social Security for State Workers and lastly the Health Department. The financial needs for both diseases will represent approximately 13%–15% of the total budget allocated to the uninsured population and 15%–17% for the population insured depending on the region.

[Cost analyses of medical care for schizophrenia and depression in México, 2005-2013]

The study aimed to analyze the costs of medical care for mental disorders in the Mexican health system. This was a retrospective cross-sectional evaluation study. As markers for the problem, the study selected two of the principal psychological processes in mental disorders in recent years: depression and schizophrenia. Annual accumulated incidence was identified based on epidemiological reporting by type of institution in 2005-2013. The mean annual case management cost was determined with the instrumentation and consensus technique, identifying the production functions, types of inputs, costs, and amounts of inputs ordered, concentrated in the mean case matrix. Finally, an econometric adjustment factor was applied to control the inflationary effect for each year in the study period. Mean annual case management cost was USD 2,216.00 for schizophrenia and USD 2,456.00 for depression. All the institutions in the Mexican health system showed upward and constant epidemiological and economic trends. The total cost for the two disorders in the last year of the period (2013) was USD 39,081,234.00 (USD 18,119,877.00 for schizophrenia and USD 20,961,357.00 for depression). The largest impact for the two disorders combined was in institutions serving the population without health insurance (USD 24,852,321.00) versus the population with private insurance (USD 12,891,977.00). The cost of meeting the demand for services for the two disorders differs considerably between institutions that treat the population with private health service versus the population without, and is higher in the latter. The study's epidemiological and economic indicators provide evidence for decision-making in the use and allocation of healthcare resources for these two disorders in the coming years.

Decision-making Process by Users and Providers of Health Care Services During the AH1N1 Epidemic Influenza in Mexico: Lessons Learned and Challenges Ahead

OBJECTIVE

The aim of the study was to analyze, using a decision analysis approach, the probability of severity of illness due to delayed utilization of health services and inappropriate hospital medical treatment during the 2009 AH1N1 influenza epidemic in Mexico.

METHODS

Patients with influenza AH1N1 confirmed by the polymerase chain reaction (PCR) test from two hospitals in Mexico City, were included. Path methodology based upon literature and validated by clinical experts was followed. The probability for severe illness originated from delayed utilization of health services, delayed prescription of neuraminidase inhibitors (NAIs) and inappropriate use of antibiotics was assessed.

FINDINGS

Ninety-nine patients were analyzed, and 16% developed severe illness. Most patients received NAIs and 85.9% received antibiotics. Inappropriate use of antibiotics was observed in 70.7% of cases. Early utilization of services increased the likelihood of non-severe illness (cumulative probability CP = 0.56). The major cumulative probability for severe illness was observed when prescription of NAIs was delayed (CP = 0.19).

CONCLUSION

Delayed prescription of NAIs and irrational use of antibiotics are critical decisions for unfavorable outcomes in patients suffering influenza AH1N1.

Diabetes, a global public health challenge with a high epidemiological and economic burden on health systems in Latin America

This manuscript presents the results of an analysis that highlights the challenges of diabetes as a global public health problem. The analysis was conducted in two phases: the first phase deals with primary data and results of a longitudinal study to provide evidence on the Mexican case. Regarding epidemiological changes between 2014 and 2016, there is an increase of 9-13% (p < .001). Comparing the economic burden from epidemiological changes in 2014 versus 2016 (p < .05), there is a 26% increase. The total amount spent on diabetes in 2015 (US dollars) was $ 8,974,662,570. This includes $ 3,981,426,810 in direct costs and $ 4993,235,752 in indirect costs. The second phase emphasises the analysis of diabetes as a major global public health challenge in the Americas. For this purpose a comparative analysis of epidemiological trends was carried out in seven selected Latin American countries (LACs). The results of both phases showed evidence leading to the conclusion that if the risk factors and models of health care remain as they currently are in LACs, there will be a high economic impact to patients' pockets and to health systems, which could lead to financial collapse.