Academic literature on the topic 'Long day care'

In Reply.— We appreciate the comments of Gielen et al on our study examining the risk of injuries to children in day care compared with the risks of injuries to children at home. Injury control, a problem ignored for far to long, is finally beginning to attract a sizeable number of investigators and practitioners. Nevertheless, resources are still extremely scarce, and we encourage others involved in this area to use criteria similar to those used at the Harborview Injury Prevention and Research Center in choosing a topic for intervention: the injuries must be frequent, they must be severe, and an effective intervention should exist.

Americans over age 65 constitute a larger percentage of the population each year: from 14% in 2010 (40 million elderly) to possibly 20% in 2030 (70 million elderly). In 2015, an estimated 66 million people provided care to the ill, disabled, and elderly in the United States. In 2000, according to the Centers for Disease Control and Prevention (CDC), 15 million Americans used some form of long-term care: adult day care, home health, nursing home, or hospice. In all, 13% of people over 85 years old, compared with 1% of those ages 65 to 74, live in nursing homes in the United States. Transitions of care, among these various levels of care, are common: Nursing home to hospital transfer, one of the best-studied transitions, occurs in more than 25% of nursing home residents per year. This article follows one patient through several levels of care.

The dichotomy caused by the National Health Service Act, Section 28, which split the responsibility for the mentally disordered between the Minister of Health and local authorities has remained with us. Along with a separate GP service this dichotomy has caused inconsistencies, confusion and overlap in day care facilities. Although psychiatric day care has now become accepted as an essential element in the comprehensive psychiatric care of the mentally ill, its development has been unplanned and there is a great regional variation (Vaughan, 1983).

The Quality Improvement and Accreditation System (QIAS) is designed to create benchmarks for quality long day care (LDC). As accreditation does not influence employment conditions, high staff turnover and departures from the industry of qualified and experienced workers is the result. High staff turnover and industry attrition of workers can be abated if both the determining and contributing factors of quality care are simultaneously addressed. Failure to examine and improve the extrinsic rewards of work in LDC will dilute the child-centred outcomes of accreditation as well as the occupational commitment of child care workers.

Yoga classes are an increasingly popular trend in early childhood education and care services. The purpose of this research is to examine how yoga classes are included in the programs of long day care centres, and how links are drawn between the components of yoga classes, and yogic strategies, and the curriculum framework Belonging, Being and Becoming: The Early Years Learning Framework for Australia, and mandated requirements that guide all service providers (and staff and educators in children’s services) to provide an environment that supports children’s growth across all developmental domains. Until recent years, yoga was not considered a suitable activity for environments such as schools and children’s services. In general, only adults attended yoga classes held in specified yoga venues. However, those who study the life skills that are advocated in yoga philosophy agree that yoga is a way of living that supports a healthy lifestyle. According to the National Quality Standard guide, the early childhood curriculum and daily programs should provide children with strategies that will lead to a healthy adulthood. This research project explores the links between the content of the yoga classes in relation to the Early Years Learning Framework and the provision of programs that scaffold children’s levels of development. This research project examines the question: What happens when yoga is included in long day care programs? Sub questions: l How many long day care services in the Gold Coast offer yoga? 1 How does yoga fit with the legislated ECEC curriculum frameworks? 1 What matters to educators and parents about including yoga in the long day care programs? Case study research methodology is used to examine how yoga is included in long day care services. Part One of the research project uses surveys to scope the early childhood education and care long-day care centres that include yoga classes in their service delivery. Part Two uses interviews to examine the perceptions of early childhood educators and yoga teachers about yoga in the early education and care programs. On the surface, yoga classes are valued as part of the curriculum for services that include yoga in the weekly program. Early childhood services encapsulate a social culture of their own, that includes the beliefs and values of the staff and the families using the services. This social culture needs to be considered when planning and implementing pedagogical strategies in the daily program. However, this project found that there is a paucity of research about the pedagogy of yoga in early childhood services. This project pinpoints the need to examine the use of extracurricular classes, including yoga, as part of the delivery of programs in early childhood services. Additionally, there is a need for research about how practising yoga can support early childhood development and provide strategies for continued health and well-being through a socio-cultural lens. This research project concludes that there is no empirical evidence to confirm that yogic practices or extra-curricular yoga classes in early childhood increase the potential for health and well-being in adulthood. Recommendations for early education and care long-day care centres are three-fold. Firstly, it is necessary to collaborate with all stakeholders including children about the opportunities to participate in yoga classes. Secondly, we must examine the content activities of the yoga classes and practices and how they fit with the aspirations and expectations of parents and children. Finally, the third step is to assure a match between what the curriculum requires for children’s development and the content activities in the yoga classes. This has particular relevance to the professional knowledge of educators and yoga teachers. These recommendations are important considerations in the decision-making about the inclusion (or not) of yoga classes in the delivery of the curriculum of long day care services.
Thesis (Masters)
Master of Medical Research (MMedRes)
School of Medical Science
Griffith Health
Full Text

Background: Day care services support older people with multiple long term conditions (LTC) within the community to age in place. This salient topic is given little attention by researchers. Day care services models are complex and outcomes for service users unknown. In the UK, in response to wider policy reforms local authority models have been outsourced to a range of organisations, including Charitable and Voluntary services. This thesis aims to understand the models of day care provided in the community and the subsequent outcomes for users and their families. Methods: This is an exploratory study comparing outcomes for users across five different service types: firstly comparing day care provided by Paid staff services, Voluntary services and Blended services (provided by staff and volunteers) and secondly comparing services provided in urban and rural areas, with a particular focus on health inequalities. Mixed Methodology was used. Observations using focussed ethnography and semi structured qualitative interviews with staff and volunteers provided a greater understanding of the type of provision. Quantitative measures were used at 3 time points over 12 weeks of attendance with clients new to day care to assess outcomes using tools for health status and loneliness. Findings: Data was collected from nine day care centres across seven services. 94 clients and 16 carers attending day care were recruited. 36 semi structured interviews were undertaken with clients, carers, staff and volunteers at the services. At baseline there were no differences across services types in the numbers of long term conditions reported by service types but there were significant differences between rural and urban services (rural mean LTC 5.2, urban mean LTC 4.2, p0.04). A larger proportion of clients attending Blended and volunteer led services reported a reduction in loneliness. When adjusted for other baseline variables in logistic regression model, likelihood of reduction in loneliness was increased in Blended (OR=2.28) and Voluntary (OR=2.16) services compared to Paid staff service. People using Blended and Voluntary services reported better or same health outcomes across most EQ5D3L domains than Paid services. Observations and interview data suggests that the differences in outcomes at Blended and Voluntary services may be due to the delivery of activities promoting self-worth and facilitating links to the wider community. Conclusion: This thesis concludes that day care provides vital support for frail older people living at home and their volunteers can deliver effective support with favourable outcomes. It is suggested that activities that promote self-worth and provide links to the community may facilitate positive health outcomes and reduce loneliness. Preparation of such activities can be implemented with minimum resources, providing cost effective interventions for providers to deliver.

The transmission of infectious diseases in childcare centres regularly occur and can pose a risk to the health of young children. This research explored the issues that support or impede good infection prevention measures and found gaps in policy and training that, if addressed, could help reduce disease transmission risk. The findings from this research will help inform national conversations to ensure evidence-based infection prevention measures are part of standard practice in the early childhood education and care sector.

The case study research of five early childhood teachers drew upon the theoretical framework of social constructivism to investigate what keeps early childhood teachers working in long day care. Examining the ecology of long day care in light of the national reform agenda for Early Childhood Education and Care, the research identified the individual and contextual factors that enabled and challenged the teachers’ work in long day care. The study contributes empirically-based insights and offers practical strategies to support the recruitment and retention of early childhood teachers in long day care.

Technological advances during the past 30 years have dramatically improved survival rates for children with life-threatening conditions (preterm births, congenital anomalies, disease, or injury) resulting in children with special health care needs (CSHCN), children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who require health and related services beyond that required by children generally. There are approximately 10.2 million of these children in the United States or one in five households with a child with special health care needs. Care for these children is limited to home care, medical day care (Prescribed Pediatric Extended Care; P-PEC) or a long term care (LTC) facility. There is very limited research examining health outcomes of CSHCN and their families. The purpose of this research was to compare the effects of home care settings, P-PEC settings, and LTC settings on child health and functioning, family health and function, and health care service use of families with CSHCN. Eighty four CSHCN ages 2 to 21 years having a medically fragile or complex medical condition that required continual monitoring were enrolled with their parents/guardians. Interviews were conducted monthly for five months using the PedsQL TM Generic Core Module for child health and functioning, PedsQL TM Family Impact Module for family health and functioning, and Access to Care from the NS-CSHCN survey for health care services. Descriptive statistics, chi square, and ANCOVA were conducted to determine differences across care settings. Children in the P-PEC settings had a highest health care quality of life (HRQL) overall including physical and psychosocial functioning. Parents/guardians with CSHCN in LTC had the highest HRQL including having time and energy for a social life and employment. Parents/guardians with CSHCN in home care settings had the poorest HRQL including physical and psychosocial functioning with cognitive difficulties, difficulties with worry, communication, and daily activities. They had the fewest hours of employment and the most hours providing direct care for their children. Overall health care service use was the same across the care settings.

Background: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the U.S. Acute myocardial infarction (AMI), with or without ST-segment elevation, is a common presentation of coronary heart disease and affected more than 800,000 American adults in 2010. The overall goal of this dissertation was to examine decade-long trends in the extent of delay in the receipt of a primary percutaneous coronary intervention (PCI) among patients hospitalized with ST-segment elevation myocardial infarction (STEMI), 30-day hospital readmission rates in patients having survived an AMI, and multiple decade long trends in 1-year post-hospital all-cause mortality, as well as factors associated with these outcomes, among patients hospitalized with AMI. Methods: Data from the Worcester Heart Attack Study, a population-based chronic disease surveillance project that has been carried out among adult residents of the Worcester, MA, metropolitan area, hospitalized with AMI on a biennial basis from 1975 through 2009 at all medical centers in central MA, were used for this dissertation. Results: Between 1999 and 2009, among patients hospitalized with STEMI, the likelihood of receiving a primary PCI within 90 minutes after emergency department arrival increased dramatically from 1999/2001 (11.6%) to 2007/2009 (70.5%). Between 1999 and 2009, among hospital survivors of an AMI, the 30-day all-cause rehospitalization rates decreased from 1999/2001 (20.3%) to 2007/2009 (16.7%). The overall cause-specific 30-day rehospitalization rates due to CVD, non-CVD, and AMI were 10.1%, 7.1%, and 1.8%, respectively, during the years under study. Between 1975 and 2009, among hospital survivors for a first AMI, the 1-year post-discharge mortality rates remained relatively stable from 1975-1984 (12.9%) to 1986-1997 (12.5%), but increased during 1999-2009 (15.8%). We identified several demographic, clinical and in-hospital treatment factors associated with an increased risk of failing to receive a primary PCI within 90 minutes after emergency department arrival, 30-day readmissions, and 1-year post-discharge mortality. Conclusions: Our findings can hopefully lead to the enhanced development of innovative, patient-centered, intervention strategies which can further improve the treatment and transitions of care, as well as short and long-term prognosis, of men and women hospitalized with AMI.

Across Australian long day care centres, thousands of early childhood (EC) educators face enduring challenges adversely impacting their pay, conditions, and workplace retention. Despite such challenges, significant numbers of EC educators continue to work in their roles over the long-term. Data was collected from 18 study participants and viewed through a professional identity framework comprising the dimensions of continuity, belonging and attachment, status and esteem, and mastery. The analysis shed light on the reasons underlying EC educator decisions to continue working in long day care centres within the broader context of historical and current policy approaches.

The purpose of this study was to compare and measure the long term effectiveness of the rehabilitative day treatment program at San Bernardino County's Department of Mental Health. This current study was completed in 2005 and is a follow up study tracking the long term effectiveness of the program.

This thesis generated practical insights into how membership of a multidisciplinary network supported the professional practice of a small group of service leaders working in long day care in a Queensland community characterised by complexity. Nested within an Australian Research Council funded national Early Childhood Education and Care Workforce Study, this study contributes to the identification of effective strategies to grow and sustain a professional early years workforce.

AbstractThe Learning Centre is an important part of the Walker Unit Program as it provides structure to the day and helps the young person to regain confidence in their cognitive ability after often a long absence in education and learning, and it supports the young person in the transition to an appropriate educational setting after discharge.

AbstractDiscussion on toddlers’ outdoor play practices in various cultural spaces is rare in literature. In Australia, toddlers’ physical development and well-being is promoted but less attention is given to cultural nuances of outdoor play. We ask the question: How does outdoor play impact on toddlers’ imagination and cultural formation? Conducted in three Australian long day care (LDC) sites, an ethically approved project “Studying babies and toddlers: Cultural worlds and transitory relationships” examines the process of three Australian toddlers’ outdoor enculturation. The concepts of imagination and play from Vygotsky’s cultural-historical theory are drawn upon in relation to Hedegaard’s institutional practices model, to link contextual relations between society, community and family. Cultural formation processes in toddlers’ outdoor play, we argue, are more completely understood when daily life across home and local community is acknowledged. Data findings illustrate complexity of movement and experimentations in cultural conditions, where different spaces hold possibilities for imaginative transformations in toddler’s play. Implications suggest toddlers’ imaginative and culturally responsive outdoor play aligns with availability of interested adult/peers, shared family and community values, and varied local spaces. In this way, affective and dynamic outdoor interactions imbue cultural formation of toddler’s play and imagination with local personal meaning.

AbstractDecision makers in the tourism sector deal with various issues and need high-quality information to support their decisions. We propose a data-centric approach that analyses historical point of interest (POI) check-in data to determine parameters for an Agent Based Model (ABM). ABM simulation is then run multiple times to simulate possible outcomes in terms of the tourist flow. We have tested the proposed approach on the city of Salzburg using check-in data from Salzburg Card users across 29 POIs. These data were used to parameterize the ABM model with the number of people, the number of POIs a person visits per day, and the preference for selecting POIs to visit. The simulation was performed in GAMA ABM platform and the spatial environment was based on buildings and roads from OpenStreetMap (OSM). Simulation for the duration of 1 day has been repeated 50 times to generate POI visiting patterns. The simulation results have been compared to the ground truth data for the same day and they show that the approach can recreate the long-term pattern of POI visits, but has over-estimated several POIs that had lower visitor counts on that specific day.

Post-acute care (PAC), interchangeable with intermediate care, is the key to the success of healthcare services for older people. Due to the need for longer periods of recovery from acute insults, PAC provides the opportunities for these patients to regain functional independence, as well as reduction in hospital readmission and premature long-term care placement. Moreover, the functional recovery obtained from PAC services is associated with the reduction in one-year mortality by 62%. Different models of PAC services have been developed internationally, including home care models, community hospitals, day hospitals, nurse-led units, and community rehabilitation teams. The success of PAC depends on person-centred care with a multidisciplinary approach and comprehensive geriatric assessment, which is consistent in different PAC models. Some specific clinical conditions occurring in PAC possess unique characteristics and impact on PAC outcomes. These conditions are not exclusive to PAC, but their presence may strongly influence quality of care.

Fruits and vegetables are important parts of healthy eating and they provide excellent sources of vitamins, minerals, and dietary fiber in our diet. Those who consume fruits and vegetables regularly have a reduced risk of many chronic diseases. According to the WHO, inadequate consumption of fruits and vegetables may have contributed to as much as 14% of gastrointestinal cancer deaths and 11% of deaths resulted from ischemic heart disease worldwide. Since 2011, Hong Kong has been promoting a “2 Plus 3 a day” diet campaign aiming to raise the general public's awareness on consuming a minimum of 2 portions of fruits and 3 portions of vegetables a day. However, recent statistics showed that nearly 81% of people aged 18 – 64 failed to meet this requirement. This paper focuses on investigating the determinants of fruits and vegetables consumption behavior among university students in Hong Kong.

The project in question here, as described by its designer, the architect Stephen Witherford, is conceptualized as an “almshouse for the twenty-first century”. Located on a high street in the inner-city neighbourhood of Bermondsey, South London, it provides housing for around ninety elderly people. Designed to be open and, to an extent, continuous with the public spaces and social interactions of the high street rather than merely as an object building contained and defended within the boundaries of its site, it has been conceived by the practice Witherford Watson Mann as a node in a complex network of caring practices, relationships and spaces that extend out into the surrounding neighbourhood and beyond. As such, it exemplifies a trend in the design of eldercare in the UK, as in many other nations globally, involving the development of what are termed deinstitutional models of care in place of traditional models within bounded institutional settings. These new models encompass varied combinations of formal care services and informal types of care made available to people living outside of traditional institutions such as nursing homes. They pertain to a wide array of spaces too, from the long-term family home where someone may wish to age-in-place, to day care centres where people may go for a few hours to receive particular forms of support beyond the home, to residential accommodation such as the almshouse where people may live relatively independently but with help, services and resources close at hand.

In recent years ICU-care and ICU-management of the critically ill patient is paying more attention to long term effects of the stay on the ICU and of the negative consequences of immobilization, long periods of bed rest, mechanical ventilation and medication aimed at pain reduction and sedation. Immobilization in bed affects practically all body conditions within a very short time frame: ranging from less than an hour to a few days. Some of these effects are reversible, some are not and may result in negative long term effects of the stay on the ICU. Recently new devices and equipment have been developed that enable mobilization of ICU patients at an extremely early stage, even without the patient being aware of being mobilized and being ventilated. This so-called Early Mobilisation (EM) has shown to be safe, feasible and improves outcomes both in the short term and especially also in the long run. There is a gradually building body of knowledge demonstrating the positive effects. In spite of these positive developments mobilizing critically ill and very passive patients in the complicated and often crowded ICU environment is also a first degree ergonomic challenge. Currently occupational musculoskeletal disorders are already prevalent in an ICU environment among nurses and physical therapists across the world. Lifting, assisting and supporting these complicated patients often attached to monitoring and (live) supportive equipment 24 hours a day can be very strenuous. EM requires considerable additional effort from these workers. These ergonomic implications will need to be resolved if an EM policy is to be successfully implemented. Therefore a study was undertaken describing the current situation and the potential of EM for the ICU’s in Dutch hospitals. The results indicate a whole array of different descriptions of EM and a lack of consensus, the lack of sufficient and adequate equipment especially when it comes to ergonomic considerations for the nurses, a lack of knowledge of what is required for EM and a lack of up-to-date protocols indicating safe procedures for both patient and nurse. Nevertheless most nurses are convinced of the need for and relevance of EM and see opportunities there. However: they are mostly focused on the patient side of EM and have not sufficiently analyzed the potential consequences for their own health.

Physically disabled community in Sri Lanka is not receiving sufficient attention with reference to the conduciveness of their living environments. The patients who are harrowed with mobility impairments should be supported to overcome challenges which hinder the smooth functioning of day today physical activities while maintaining their psychological health by incorporating disabled-friendly, optimum healing design interventions. In view of this, an attempt was made to determine the impact of interior colours to reduce depression, anxiety and stress levels of disabled individuals. The investigation was executed with reference to wall colour of patient’s (n=15) bedrooms of a selected rehabilitation centre, at Ragama. The impact of three selected hues (blue, yellow and green) were tested by installing colour panels on the sidewall of the beds, allowing the participants to be exposed to each colour for three consecutive days. Depression, anxiety and stress levels of participants were measured using DASS-21. Impact of green colour was found to be more favourable to reduce depression, anxiety and stress levels of participants over blue and yellow. It is recommended to extend this study further to test different hues, shades and intensities of green colour with long-term exposure, to enhance psychological health and well-being of disabled patients in health care facilities.

Introduction: In 2021, it is estimated that Brazil will have 66,280 new cases of breast cancer. Unfortunately, around 55% of the cases treated by the Brazilian Unified Health System (SUS) are symptomatic and are in advanced stages. The long time before biopsy and the late start of treatment contribute to the progression of these tumors, with worsening prognosis. In order to reduce the time to start therapy, we implemented a model of integrated multidisciplinar care with high resolution (CARE). Objectives: The purpose of this work is to demonstrate the main barriers and the solutions found to reduce the time of treatment start at the institution, according to Law no. 12,732, which recommends the start of therapy within 60 days of diagnosis, preventing the progression of the disease and reducing mortality. Methods: The information was registered at the Women´s Health Reference Center (CRSM) data colletion system from the first day of care until the start of therapy (surgery or chemotherapy), in a cross-sectional cohort of 8,357 patients from January 2011 to December 2018. Patients referred were seen at CARE and underwent consultation with an anesthesiologist or oncologist in the service having a previous appointment to start treatment. Results: After the integration of anestheologists and clinical oncologists, in 2014, there was a significant reduction (from 55 to 38 days) in the time of treatment start. Discussion: CARE started integrated care with biopsy on the same day as the initial consulation in 2006, reducing returns and time to diagnosis from 90 to 15 days. CRSM serves more than 1,200 new cases/year, about 30% of SUS cases in the city of São Paulo (SP). A 12-week surgical delay for all breast cancer patients from one year (for example in the COVID 19 pandemic) would lead to 1,400 excess deaths in the United Kingdon and 6,100 in the United States, assuming surgery was the first choice of treatment for 83% of the patients. Conclusion: Our experience shows that the training of mastologists to perform a biopsy in the first consultation, that the public/private partnership to obtain the anatomopathological and immunohistochemical results in 15 days and that a multidisciplinary integrated care is possible, allowing the average onset of treatment to be close to 30 days, which may reduce the proportion of advanced cases in SUS.

Background: Shift work is essential for many occupations like in the Emergency Medical Service that provides critical services that must be available all hours as a result of the irregularly day and night nature work (e.g., 9 p.m to 7:30 am ) with long-duration shifts (e.g., 24h and 48h) they could end up with a higher risk of disturbances in hemodynamic status which is contributed to (shock, heart failure, pressure changes, Sleep deficiency) along with mental health issue Objective: we aim to compare the blood pressure, heart rate, and O2 saturation and investigate the effect of demographic that includes (BMI, age, sex, educational level, mental status, memory, and decision-making ability. ) symptoms, and substance consumption (including caffeine, tea, energy drink, alcohol, smoking, multi-vitamin ..etc) between two group night shift and day shift Method: this study will be conducted in private hospitals and public hospitals in Jordan (Amman and Irbid ) and its design is a cross-sectional observational where adult health care providers will be invited to participate in completing an interviewer administration questionnaire Results: the high percentage of night medical workers faced a problem in many aspects including sleep disturbances, higher pressure, high caffeine intake, low focus, and decision-making ability along with social and family issues and mental health disturbances Conclusion: so we could conclude that medical night Shift work is associated with impaired alertness and low efficacy due to sleep loss and circadian disturbances so the performance remains mainly impaired during night shifts and the ability to focus and solve the problem and memorize information become lower with time In the end, we hope that medical institutions and hospitals would care more about the working environment not only the physical side but also mental health which should be put under the consideration Keywords: hemodynamic status, night shift, mental health, cardiovascular disease, social life

This paper deals with the development of a solar stove system that synthesizes the concepts of a reversible chemical reaction using CaO and water for heat generation, with that of the concentrated solar radiation for regeneration. A solar stove to take care of the needs of a standard family and which can be used at any time of the day has been designed, fabricated and used for experimental testing. A paraboloid solar concentrator has been conceived, designed and built to be used as a community facility in the neighborhood of the family for the regeneration of CaO from Ca(OH)2. Different aspects encompassing heat transfer, reaction kinetics, water injection along with structural integrity and safety have been given due consideration as also the implementation technicalities with regard to capacity, cost, user friendliness, efficiency, and adaptation of locally available materials etc. These and the experimental test results of the heat generation part of the stove system are presented and discussed. This stove system has the innate potential to endear itself to the end user and upon completion of the testing of the regeneration part can turn out to be that long term solution, one is looking for.

ABSTRACT The digital age and advances in technology are introducing a new attitude to medical care, bringing about significant technologies such as exergames, enhancing the promotion of active and healthy aging. This study aimed to investigate possible differences in perceived quality of life factors between older adults participating in traditional dance and physical training using new technologies, comparing them with sedentary people (control group). The study involved 84 women, with an average age of 67.6 years from Day Care Centers of the Municipality of Thessaloniki, Greece. The program duration was six months (24 weeks) with a frequency of twice a week and each session lasted 75 minutes. An evaluation was performed both before and after the end of the interventions with specialized tools that assess the physical status and functional capacity of the individuals, as well as questionnaires that assess the quality of life indicators. Regarding the usability of the systems, integrated the System Usability Scale (SUS). Statistical analysis was performed with the statistical package SPSS 26. According to the results, the intervention groups compared to the initial measurement showed a statistically significant improvement in variables that assess strength, balance, aerobic capacity, gait to avoid falls, stress, depression, and quality of life in general, in comparison with the control group (p ≤ .05). The SUS scores ranged around 80 for both systems, so it seems that the practical implementation of the programs has the potential to provide the expected results. In conclusion, these innovative technological solutions in collaboration with expert health professionals, can improve the quality of life of older adults, remain autonomous and independent, but at the same time active members of society for a long time.

In parallel with the development of modern health systems and the growth of the welfare state, diseases have shifted towards chronic diseases. Today, instead of rapid-onset infections, most resources are focused on the long-term treatment of mostly lifelong chronic conditions. The condition for the effective use of therapies is to take the specified dose with the prescribed frequency and for the required period of time. If these parameters are met, we can talk about patient collaboration or adherence. For certain diseases and treatments, adherence is critically low. In the case of complex preparations to be taken several times a day, or diseases that do not cause serious, noticeable complaints, the initial number of patients treated is reduced to a fraction within a short time. As a result, economic harm is perceived not only by the patient but also by all those involved in the health care system, including pharmaceutical companies. However, the factors influencing patient collaboration vary widely. In order to achieve high adherence, the goal is to develop health services that coordinate the actors involved, the infrastructure, the communication, the material components to improve the user experience. As a user-centered methodology, service design can play a prominent role in the design of therapeutic services, contributing to the reduction of uncertainties in innovation processes. In my study, I assess the digital toolkit of patient education in Hungarian society. The aim is to explore digital tools and technologies that can contribute to the development of health awareness and education so that both science and the pharmaceutical and technology companies that exploit it can apply the results of research.

Preterm labor is the leading cause of neonatal mortality and accounts for 70% of the total cost of neonatal health care. Premature softening of the cervix has been identified as one of the primary causes of preterm labor. As the biochemistry of the cervix is distinct between the proximal and distal portions, the objective of this study was to determine the viscoelastic properties of these portions in mid-pregnancy (Day 15–16) relative to virgin Long-Evans rats. This will serve to establish baseline data for future studies that will aim to induce preterm labor in this model. The cervix was divided into distal and proximal portions that were tested independently. Each portion was tested in unconfined compression to 20% strain and held for 4 minutes followed by a recovery period of 30 minutes. The stress-relaxation response was modeled using the quasi-linear viscoelastic (QLV) theory developed by Professor Fung (1972). The parameters governing the viscous response, C, τ1 and τ2, were found to be significantly different between virgin and pregnant tissues in distal portions; however τ2 was the only viscous parameter found to be significantly different for the proximal portion (p<0.05). These results show an increased magnitude of the viscous response with more rapid relaxation for the pregnant cervix. Future studies will evaluate the cervix both postpartum and upon induction of preterm labor. Additionally, contractile and biochemical assays will be used to correlate these changes in passive behavior to active properties and tissue constituents.

Abstract Integrity programs utilize advanced inspection technology that generate gigabytes to terabytes of information for each inspection performed. Discussions of “Big Data” have permeated across all major platforms in the pipeline industry, from academic institutions, industry associations, to even commercial integrity management solution providers. While the management and governance of data is typically in the domain of Information Technology (IT) services, organizations are facing a data consumption problem: they are not able to fully realize the business value in their data. Data is generated at a far greater pace than most organizations can keep up with. There is a widening gap between the potential value suggested by the data, and the actual value in the outcomes achieved from the data itself. Bridging the value gap requires an innovative mindset that can conceive new approaches towards the application of data. Innovative solutions to existing problems can help organizations enhance their safety culture and work effectively towards achieving Environmental, Social, and Governance (ESG) goals. However, cultivating that mindset can be challenging in fast-paced, safety-critical environments where workday hours are filled with multiple priorities and stakeholder requests. Furthermore, the consumption of data is not without its risks. Aside from broader issues such as information security and ethical abuse, the unintentional misinterpretation of data is a concern that directly impacts the ability of operators to manage the safety of their pipeline systems. While technology and software applications can help mitigate risks associated with data misuse, a culture promoting data literacy and experimentation fosters a higher-level of care and ownership towards the responsible use of data. This paper presents the outcomes from a 2021 pilot program that combines data competency building with the cultivation of an innovative mindset. The program used a team-based “hackathon” like competition to provide a dedicated time and safe space for responsible, lean experimentation of digital problems. In this environment, teams explored innovative solutions to their day-to-day integrity challenges. The program develops technical competencies in data literacy, digital applications, scripting, and analytics; and soft skills including unstructured teamwork, communication, leadership, and a growth mindset. Projects leveraged solutions in areas of data visualization, analytics, automation, and machine learning to drive improvements in effective and efficient integrity management. Along with describing the framework of the program, the paper will also cover learnings from the experience, which highlight the importance of long-term investment in building digital competencies and effective, collaborative problem-solving skills. By empowering talent within an organization to drive their own innovative solutions, organizations can improve employee engagement and cultivate a greater sense of data stewardship, all while enhancing their integrity programs.

Introduction: The role of surgery for Peritoneal carcinomatosis (PC) has slowly evolved from palliation to potential curative intent. Attempting to remove all visible tumor deposits, “surgical cytoreduction” (CRS) was reported in 1930s for ovarian cancer and eventually became an accepted therapy with proven survival benefit. The new approach of combining CRS and Hyperthermic intraperitoneal chemotherapy (HIPEC) to treat peritoneal metastasis offer hope for long term survival in this group of patients. The risk and benefit of this approach continued to be debated. A prospective study was conducted to understand the perioperative outcomes of CRS & HIPEC. Aim: To evaluate the perioperative outcomes associated with CRS & HIPEC in Advanced and Recurrent Epithelial Ovarian Cancer with PC. Methods: Prospective analysis of patients undergoing CRS & HIPEC from November 2014 to July 2015 was done. Inclusion criteria included localized disease in peritoneal cavity, no distant metastasis and PS <2. Grade 3/4 complications from day of surgery until 30 days postoperatively were recorded. Results: We performed CRS & HIPEC in 20 patients from Nov 2014 to June 2015. HIPEC Plus regimens included Cisplatin (50 mg/m2) and Lipodox (15 mg/m2) intraperitoneally and Ifosphamide (1300 mg/m2) & Mesna (260 mg/m2) Infusion time was 90 minutes with a temperature range of 41-43 °C. Out of 20 patients 6 (30%) underwent primary debulking surgery and 14(70%) underwent secondary debulking surgery. PCI score ranged from 2-26 (mean 13.65). Mean operating time was 6.42 hrs and average blood loss was 1046 ml. Average hospital stay was 8 days and SICU stay was 4.9 days (range 3-14 days). Total 26 adverse events were observed of which grade 1 were 11 (42%), grade 2 were 8 (30%), grade were 3 (11.5%) and grade4 were 2 (8%). Most common complication was hematological (8) followed by respiratory (6), sepsis (4) renal (2), GI (2). 4 patients (5 events) developed grade3 or 4 complications in the form of septicaemia, pulmonary embolism, GI fistula of which 2 patients expited and remaining recovered although required prolonged hospitalization. Increased morbidity were observed in cases with symptomatic relapse, higher PCI score and CA 125 level higher than 250 U/ml. Most of the adverse events were grade 1 and 2 and were managed by observation only or GCSF support, transfusions and other minor interventions. The combined grade 3-4 morbidity was 20% (4out of 20) which consisted of neutropenia, infection and respiratory complications. One patient required relaparotomy and two patients expired attributed to pulmonary embolism and septicaemia respectively. Conclusion: Enthusiasm associated with improvement in survival is often dampened by increased perioperative mortality and morbidity figures and therefore CRS & HIPEC has not yet been considered standard of care by many centres. HIPEC after extensive cytoreductive surgery for ovarian cancer is a procedure whth acceptable morbidity that patients can tolerate. More follow up is needed to determinr the effect of HIPEC on survival. Till such time more data are obtained by way of larger randomised trials, this approach remains investigational.

As a student undertaking a Longitudinal Integrated Clerkship (LIC)1 based in a GP practice in a rural community in the North of Scotland, I have been lucky to be given responsibility and my own clinic lists. Every day I conduct consultations that change my practice: the challenge of clinically applying the theory I have studied, controlling a consultation and efficiently exploring a patient's problems, empathising with and empowering them to play a part in their own care2 – and most difficult I feel – dealing with the vast amount of uncertainty that medicine, and particularly primary care, presents to both clinician and patient. I initially consulted with a lady in her 60s who attended with her husband, complaining of severe lower back pain who was very difficult to assess due to her pain level. Her husband was understandably concerned about the degree of pain she was in. After assessment and discussion with one of the GPs, we agreed some pain relief and a physio assessment in the next few days would be a practical plan. The patient had one red flag, some leg weakness and numbness, which was her ‘normal’ on account of her multiple sclerosis. At the physio assessment a few days later, the physio felt things were worse and some urgent bloods were ordered, unfortunately finding raised cancer and inflammatory markers. A CT scan of the lung found widespread cancer, a later CT of the head after some developing some acute confusion found brain metastases, and a week and a half after presenting to me, the patient sadly died in hospital. While that was all impactful enough on me, it was the follow-up appointment with the husband who attended on the last triage slot of the evening two weeks later that I found completely altered my understanding of grief and the mourning of a loved one. The husband had asked to speak to a Andrew MacFarlane Year 3 ScotGEM Medical Student 2 doctor just to talk about what had happened to his wife. The GP decided that it would be better if he came into the practice - strictly he probably should have been consulted with over the phone due to coronavirus restrictions - but he was asked what he would prefer and he opted to come in. I sat in on the consultation, I had been helping with any examinations the triage doctor needed and I recognised that this was the husband of the lady I had seen a few weeks earlier. He came in and sat down, head lowered, hands fiddling with the zip on his jacket, trying to find what to say. The GP sat, turned so that they were opposite each other with no desk between them - I was seated off to the side, an onlooker, but acknowledged by the patient with a kind nod when he entered the room. The GP asked gently, “How are you doing?” and roughly 30 seconds passed (a long time in a conversation) before the patient spoke. “I just really miss her…” he whispered with great effort, “I don’t understand how this all happened.” Over the next 45 minutes, he spoke about his wife, how much pain she had been in, the rapid deterioration he witnessed, the cancer being found, and cruelly how she had passed away after he had gone home to get some rest after being by her bedside all day in the hospital. He talked about how they had met, how much he missed her, how empty the house felt without her, and asking himself and us how he was meant to move forward with his life. He had a lot of questions for us, and for himself. Had we missed anything – had he missed anything? The GP really just listened for almost the whole consultation, speaking to him gently, reassuring him that this wasn’t his or anyone’s fault. She stated that this was an awful time for him and that what he was feeling was entirely normal and something we will all universally go through. She emphasised that while it wasn’t helpful at the moment, that things would get better over time.3 He was really glad I was there – having shared a consultation with his wife and I – he thanked me emphatically even though I felt like I hadn’t really helped at all. After some tears, frequent moments of silence and a lot of questions, he left having gotten a lot off his chest. “You just have to listen to people, be there for them as they go through things, and answer their questions as best you can” urged my GP as we discussed the case when the patient left. Almost all family caregivers contact their GP with regards to grief and this consultation really made me realise how important an aspect of my practice it will be in the future.4 It has also made me reflect on the emphasis on undergraduate teaching around ‘breaking bad news’ to patients, but nothing taught about when patients are in the process of grieving further down the line.5 The skill Andrew MacFarlane Year 3 ScotGEM Medical Student 3 required to manage a grieving patient is not one limited to general practice. Patients may grieve the loss of function from acute trauma through to chronic illness in all specialties of medicine - in addition to ‘traditional’ grief from loss of family or friends.6 There wasn’t anything ‘medical’ in the consultation, but I came away from it with a real sense of purpose as to why this career is such a privilege. We look after patients so they can spend as much quality time as they are given with their loved ones, and their loved ones are the ones we care for after they are gone. We as doctors are the constant, and we have to meet patients with compassion at their most difficult times – because it is as much a part of the job as the knowledge and the science – and it is the part of us that patients will remember long after they leave our clinic room. Word Count: 993 words References 1. ScotGEM MBChB - Subjects - University of St Andrews [Internet]. [cited 2021 Mar 27]. Available from: https://www.st-andrews.ac.uk/subjects/medicine/scotgem-mbchb/ 2. Shared decision making in realistic medicine: what works - gov.scot [Internet]. [cited 2021 Mar 27]. Available from: https://www.gov.scot/publications/works-support-promote-shared-decisionmaking-synthesis-recent-evidence/pages/1/ 3. Ghesquiere AR, Patel SR, Kaplan DB, Bruce ML. Primary care providers’ bereavement care practices: Recommendations for research directions. Int J Geriatr Psychiatry. 2014 Dec;29(12):1221–9. 4. Nielsen MK, Christensen K, Neergaard MA, Bidstrup PE, Guldin M-B. Grief symptoms and primary care use: a prospective study of family caregivers. BJGP Open [Internet]. 2020 Aug 1 [cited 2021 Mar 27];4(3). Available from: https://bjgpopen.org/content/4/3/bjgpopen20X101063 5. O’Connor M, Breen LJ. General Practitioners’ experiences of bereavement care and their educational support needs: a qualitative study. BMC Medical Education. 2014 Mar 27;14(1):59. 6. Sikstrom L, Saikaly R, Ferguson G, Mosher PJ, Bonato S, Soklaridis S. Being there: A scoping review of grief support training in medical education. PLOS ONE. 2019 Nov 27;14(11):e0224325.

Este documento resulta dun traballo iniciado pola Sección de Patrimonio e Bens Culturais do Consello da Cultura Galega (CCG) en outubro de 2018 e que tiña como obxectivo trazar as liñas xerais que guiarían o desenvolvemento dun foro baixo o título «Patrimonio e Sociedade». A intención era organizar este evento ao longo do ano 2020 e encamiñalo cara á reflexión e o establecemento dunhas directrices básicas arredor da xestión integral do patrimonio cultural na nosa comunidade autónoma. Finalmente, por causa do estado de alarma que vivimos no ano 2020, o foro adiouse 6 meses, prolongándose ata xuño de 2021 e rematando coa presentación deste documento. Nel plásmanse os motivos que levaron á súa realización, a estrutura, as temáticas, a calendarización e a súa metodoloxía. Inclúe tamén unha guía práctica resultante do traballo das mesas e outros materiais que se xeraron a partir das actividades desenvolvidas no transcurso do foro; en concreto, unha mesa política cos partidos que teñen representación no Parlamento de Galicia e unhas xornadas de presentación das conclusións.

Recent laboratory results confirm that it is possible to protect concrete from freezing solely using chemical admixtures and indicate that the amount of admixture required may be significantly less than previously recommended. Researchers have also verified that admixture-based freeze protection can produce concrete that is durable to winter exposure for a minimum of 20 years, through petrographic examination of core specimens obtained from past field demonstrations. Freeze protection for concrete using chemical admixtures alone has been an area of active research for 3 decades; however, the most recent methodology recommends very high addition rates of accelerating and corrosion inhibiting admixtures, which result in significant challenges, including slump loss, rapid setting, and potentially excessive temperature rise. As part of a laboratory study, researchers systematically varied the dosage of freeze protection admixtures used in concrete cured in a 23 °F environment. Preliminary findings indicate that a 50% reduction in admixture dose maintained adequate freeze protection and resulted in compressive strengths exceeding those of room-temperature controls at 7 and 28 days. The combination of improved handling, reduced cost, and verified durability associated with the use of admixtures for freeze protection makes a compelling case for broader adoption of this technique in winter operations

This technical note is an update to the previous "Water in the Time of Drought: Lessons from Five Droughts Around the World", published in 2018. It explores drought situations and policies in Spain (including the Canary Islands), Chile, Mexico, the dry corridor between Honduras, Guatemala, and El Salvador, Brazil, and South Africa. Each of these countries has recently dealt with droughts and/or developed long-term solutions to manage them. HydroBID, a tool developed by the IDB, will be presented through relevant case studies. After defining drought experiences and institutional frameworks in each country, the brief will explore the successes and challenges of national drought and water management policies. Best practices and lessons learned will be extracted from each case study to help policymakers better prepare for droughts.

Um dos maiores desafios para a economia brasileira é se consolidar em uma rota de prosperidade e bem-estar sustentável no médio e longo prazo. No entanto, superar a restriço orçamentária imposta pela pandemia e o histórico de baixa efetividade de investimentos na esfera pública no é trivial. A superaço desse desafio envolve no apenas a melhoria do gasto público, mas principalmente o aumento da atratividade do capital privado para nossa carteira de projetos de infraestrutura. Levantamentos recentes do Ministério da Economia realizados a partir dos diversos planos setoriais de infraestrutura indicam a necessidade de um choque de investimento da ordem de R$ 8,6 trilhes até 2050. A previso é que esse montante seja necessário para destravar o aumento da produtividade da nossa economia, além de garantir a universalizaço de serviços essenciais de infraestrutura para a populaço brasileira. Nesse sentido, o ferramental apresentado neste Guia oferece diretrizes para que os projetos de investimento em infraestrutura sejam feitos de maneira mais objetiva, transparente e sistemática, auxiliando o dirigente público na tomada de decises e na melhoria da qualidade dos gastos.

With moderate or light winds and a clear sky the diurnal heating which occurs near the sea surface can cause a serious reduction in the range of submarine detection, especially on shallow targets. This has usually been called the “afternoon effect", although as will be noticed below the ranges often remain short long after sun down. The heating of surface waters which causes such sharp downward refraction can of course be noted on a bathythermograph record, provided pen vibration does not confuse the upper part of the trace. Unfortunately it is the upper 20 or 30 feet of a bathythermograph curve which in the case of ships moving faster than 12 knots is often somewhat difficult to read with sufficient certainty. Moreover, in planning a days operations it is clearly desirable to know in advance how much reduction in range may be expected from diurnal warming.

This paper explores Pakistan’s electricity supply crisis that lasted from 2007 to 2015, and the ensuing contention that shaped public discourse and political events in the country. During this period, which witnessed electricity outages of up to 14 hours per day, 456 incidents of contention took place, with just under 20 per cent escalating into some form of violence. Electricity became the number one political issue in the country and was integral in shaping the outcomes of the 2013 General Election. Following the election, public authorities undertook extensive investment to expand capacity and ensure consistency in supply while evading questions about affordability and sustainability. On the surface, this appears to be a case of extensive protest working towards shaping state responsiveness. And it is true that the state now sees supply as a non-negotiable aspect in the social contract with citizens. However, a range of factors contributed to the chronology and the selective, generation-focused nature of this response. On the other hand, citizen inclusion and participation in decision-making, and issues of affordability and sustainability, which impact vulnerable and disempowered groups the most, remain absent from the political and policy conversation around energy. This suggests that while protests were useful in generating a short-term response, their long-term legacy in empowerment related outcomes is less visible.

“Social movements” are by definition informal or semi-formal, as opposed to the formal structure of a stable association, such as a club, a corporation, or a political party. They are relatively long lasting over a period of weeks, months, or even years rather than flaring up for a few hours or a few days and then disappearing (Smelser et al., 2020). There is a substantial and growing body of work dedicated to social movements, encompassing a wide range of views about how to define them (Smelser et al., 2020). This is complicated by the use of other terms which shade into the idea of “social movements”, such as grass-roots mobilisation/ movements, non-traditional civil society organisations, voluntary organisations, civic space, new civic activism, active citizenship, to name a few. There is also an implied informality to the term “social movements”, so that the research for this rapid review used both “social movement” and “informal social movement”. Thus this rapid review seeks to find out what approaches do donors use to support “informal social movements” in their programming, and what evidence do they base their strategies on. The evidence found during the course of this rapid review was drawn from both the academic literature, and think-tank and donor reports. The academic literature found was extremely large and predominantly drawn from single case studies around the world, with few comparative studies. The literature on donor approaches found from both donors and think tanks was not consistently referenced to research evidence but tended to be based on interviews with experienced staff and recipients.

1.1 Macroeconomic summary Economic recovery has consistently outperformed the technical staff’s expectations following a steep decline in activity in the second quarter of 2020. At the same time, total and core inflation rates have fallen and remain at low levels, suggesting that a significant element of the reactivation of Colombia’s economy has been related to recovery in potential GDP. This would support the technical staff’s diagnosis of weak aggregate demand and ample excess capacity. The most recently available data on 2020 growth suggests a contraction in economic activity of 6.8%, lower than estimates from January’s Monetary Policy Report (-7.2%). High-frequency indicators suggest that economic performance was significantly more dynamic than expected in January, despite mobility restrictions and quarantine measures. This has also come amid declines in total and core inflation, the latter of which was below January projections if controlling for certain relative price changes. This suggests that the unexpected strength of recent growth contains elements of demand, and that excess capacity, while significant, could be lower than previously estimated. Nevertheless, uncertainty over the measurement of excess capacity continues to be unusually high and marked both by variations in the way different economic sectors and spending components have been affected by the pandemic, and by uneven price behavior. The size of excess capacity, and in particular the evolution of the pandemic in forthcoming quarters, constitute substantial risks to the macroeconomic forecast presented in this report. Despite the unexpected strength of the recovery, the technical staff continues to project ample excess capacity that is expected to remain on the forecast horizon, alongside core inflation that will likely remain below the target. Domestic demand remains below 2019 levels amid unusually significant uncertainty over the size of excess capacity in the economy. High national unemployment (14.6% for February 2021) reflects a loose labor market, while observed total and core inflation continue to be below 2%. Inflationary pressures from the exchange rate are expected to continue to be low, with relatively little pass-through on inflation. This would be compatible with a negative output gap. Excess productive capacity and the expectation of core inflation below the 3% target on the forecast horizon provide a basis for an expansive monetary policy posture. The technical staff’s assessment of certain shocks and their expected effects on the economy, as well as the presence of several sources of uncertainty and related assumptions about their potential macroeconomic impacts, remain a feature of this report. The coronavirus pandemic, in particular, continues to affect the public health environment, and the reopening of Colombia’s economy remains incomplete. The technical staff’s assessment is that the COVID-19 shock has affected both aggregate demand and supply, but that the impact on demand has been deeper and more persistent. Given this persistence, the central forecast accounts for a gradual tightening of the output gap in the absence of new waves of contagion, and as vaccination campaigns progress. The central forecast continues to include an expected increase of total and core inflation rates in the second quarter of 2021, alongside the lapse of the temporary price relief measures put in place in 2020. Additional COVID-19 outbreaks (of uncertain duration and intensity) represent a significant risk factor that could affect these projections. Additionally, the forecast continues to include an upward trend in sovereign risk premiums, reflected by higher levels of public debt that in the wake of the pandemic are likely to persist on the forecast horizon, even in the context of a fiscal adjustment. At the same time, the projection accounts for the shortterm effects on private domestic demand from a fiscal adjustment along the lines of the one currently being proposed by the national government. This would be compatible with a gradual recovery of private domestic demand in 2022. The size and characteristics of the fiscal adjustment that is ultimately implemented, as well as the corresponding market response, represent another source of forecast uncertainty. Newly available information offers evidence of the potential for significant changes to the macroeconomic scenario, though without altering the general diagnosis described above. The most recent data on inflation, growth, fiscal policy, and international financial conditions suggests a more dynamic economy than previously expected. However, a third wave of the pandemic has delayed the re-opening of Colombia’s economy and brought with it a deceleration in economic activity. Detailed descriptions of these considerations and subsequent changes to the macroeconomic forecast are presented below. The expected annual decline in GDP (-0.3%) in the first quarter of 2021 appears to have been less pronounced than projected in January (-4.8%). Partial closures in January to address a second wave of COVID-19 appear to have had a less significant negative impact on the economy than previously estimated. This is reflected in figures related to mobility, energy demand, industry and retail sales, foreign trade, commercial transactions from selected banks, and the national statistics agency’s (DANE) economic tracking indicator (ISE). Output is now expected to have declined annually in the first quarter by 0.3%. Private consumption likely continued to recover, registering levels somewhat above those from the previous year, while public consumption likely increased significantly. While a recovery in investment in both housing and in other buildings and structures is expected, overall investment levels in this case likely continued to be low, and gross fixed capital formation is expected to continue to show significant annual declines. Imports likely recovered to again outpace exports, though both are expected to register significant annual declines. Economic activity that outpaced projections, an increase in oil prices and other export products, and an expected increase in public spending this year account for the upward revision to the 2021 growth forecast (from 4.6% with a range between 2% and 6% in January, to 6.0% with a range between 3% and 7% in April). As a result, the output gap is expected to be smaller and to tighten more rapidly than projected in the previous report, though it is still expected to remain in negative territory on the forecast horizon. Wide forecast intervals reflect the fact that the future evolution of the COVID-19 pandemic remains a significant source of uncertainty on these projections. The delay in the recovery of economic activity as a result of the resurgence of COVID-19 in the first quarter appears to have been less significant than projected in the January report. The central forecast scenario expects this improved performance to continue in 2021 alongside increased consumer and business confidence. Low real interest rates and an active credit supply would also support this dynamic, and the overall conditions would be expected to spur a recovery in consumption and investment. Increased growth in public spending and public works based on the national government’s spending plan (Plan Financiero del Gobierno) are other factors to consider. Additionally, an expected recovery in global demand and higher projected prices for oil and coffee would further contribute to improved external revenues and would favor investment, in particular in the oil sector. Given the above, the technical staff’s 2021 growth forecast has been revised upward from 4.6% in January (range from 2% to 6%) to 6.0% in April (range from 3% to 7%). These projections account for the potential for the third wave of COVID-19 to have a larger and more persistent effect on the economy than the previous wave, while also supposing that there will not be any additional significant waves of the pandemic and that mobility restrictions will be relaxed as a result. Economic growth in 2022 is expected to be 3%, with a range between 1% and 5%. This figure would be lower than projected in the January report (3.6% with a range between 2% and 6%), due to a higher base of comparison given the upward revision to expected GDP in 2021. This forecast also takes into account the likely effects on private demand of a fiscal adjustment of the size currently being proposed by the national government, and which would come into effect in 2022. Excess in productive capacity is now expected to be lower than estimated in January but continues to be significant and affected by high levels of uncertainty, as reflected in the wide forecast intervals. The possibility of new waves of the virus (of uncertain intensity and duration) represents a significant downward risk to projected GDP growth, and is signaled by the lower limits of the ranges provided in this report. Inflation (1.51%) and inflation excluding food and regulated items (0.94%) declined in March compared to December, continuing below the 3% target. The decline in inflation in this period was below projections, explained in large part by unanticipated increases in the costs of certain foods (3.92%) and regulated items (1.52%). An increase in international food and shipping prices, increased foreign demand for beef, and specific upward pressures on perishable food supplies appear to explain a lower-than-expected deceleration in the consumer price index (CPI) for foods. An unexpected increase in regulated items prices came amid unanticipated increases in international fuel prices, on some utilities rates, and for regulated education prices. The decline in annual inflation excluding food and regulated items between December and March was in line with projections from January, though this included downward pressure from a significant reduction in telecommunications rates due to the imminent entry of a new operator. When controlling for the effects of this relative price change, inflation excluding food and regulated items exceeds levels forecast in the previous report. Within this indicator of core inflation, the CPI for goods (1.05%) accelerated due to a reversion of the effects of the VAT-free day in November, which was largely accounted for in February, and possibly by the transmission of a recent depreciation of the peso on domestic prices for certain items (electric and household appliances). For their part, services prices decelerated and showed the lowest rate of annual growth (0.89%) among the large consumer baskets in the CPI. Within the services basket, the annual change in rental prices continued to decline, while those services that continue to experience the most significant restrictions on returning to normal operations (tourism, cinemas, nightlife, etc.) continued to register significant price declines. As previously mentioned, telephone rates also fell significantly due to increased competition in the market. Total inflation is expected to continue to be affected by ample excesses in productive capacity for the remainder of 2021 and 2022, though less so than projected in January. As a result, convergence to the inflation target is now expected to be somewhat faster than estimated in the previous report, assuming the absence of significant additional outbreaks of COVID-19. The technical staff’s year-end inflation projections for 2021 and 2022 have increased, suggesting figures around 3% due largely to variation in food and regulated items prices. The projection for inflation excluding food and regulated items also increased, but remains below 3%. Price relief measures on indirect taxes implemented in 2020 are expected to lapse in the second quarter of 2021, generating a one-off effect on prices and temporarily affecting inflation excluding food and regulated items. However, indexation to low levels of past inflation, weak demand, and ample excess productive capacity are expected to keep core inflation below the target, near 2.3% at the end of 2021 (previously 2.1%). The reversion in 2021 of the effects of some price relief measures on utility rates from 2020 should lead to an increase in the CPI for regulated items in the second half of this year. Annual price changes are now expected to be higher than estimated in the January report due to an increased expected path for fuel prices and unanticipated increases in regulated education prices. The projection for the CPI for foods has increased compared to the previous report, taking into account certain factors that were not anticipated in January (a less favorable agricultural cycle, increased pressure from international prices, and transport costs). Given the above, year-end annual inflation for 2021 and 2022 is now expected to be 3% and 2.8%, respectively, which would be above projections from January (2.3% and 2,7%). For its part, expected inflation based on analyst surveys suggests year-end inflation in 2021 and 2022 of 2.8% and 3.1%, respectively. There remains significant uncertainty surrounding the inflation forecasts included in this report due to several factors: 1) the evolution of the pandemic; 2) the difficulty in evaluating the size and persistence of excess productive capacity; 3) the timing and manner in which price relief measures will lapse; and 4) the future behavior of food prices. Projected 2021 growth in foreign demand (4.4% to 5.2%) and the supposed average oil price (USD 53 to USD 61 per Brent benchmark barrel) were both revised upward. An increase in long-term international interest rates has been reflected in a depreciation of the peso and could result in relatively tighter external financial conditions for emerging market economies, including Colombia. Average growth among Colombia’s trade partners was greater than expected in the fourth quarter of 2020. This, together with a sizable fiscal stimulus approved in the United States and the onset of a massive global vaccination campaign, largely explains the projected increase in foreign demand growth in 2021. The resilience of the goods market in the face of global crisis and an expected normalization in international trade are additional factors. These considerations and the expected continuation of a gradual reduction of mobility restrictions abroad suggest that Colombia’s trade partners could grow on average by 5.2% in 2021 and around 3.4% in 2022. The improved prospects for global economic growth have led to an increase in current and expected oil prices. Production interruptions due to a heavy winter, reduced inventories, and increased supply restrictions instituted by producing countries have also contributed to the increase. Meanwhile, market forecasts and recent Federal Reserve pronouncements suggest that the benchmark interest rate in the U.S. will remain stable for the next two years. Nevertheless, a significant increase in public spending in the country has fostered expectations for greater growth and inflation, as well as increased uncertainty over the moment in which a normalization of monetary policy might begin. This has been reflected in an increase in long-term interest rates. In this context, emerging market economies in the region, including Colombia, have registered increases in sovereign risk premiums and long-term domestic interest rates, and a depreciation of local currencies against the dollar. Recent outbreaks of COVID-19 in several of these economies; limits on vaccine supply and the slow pace of immunization campaigns in some countries; a significant increase in public debt; and tensions between the United States and China, among other factors, all add to a high level of uncertainty surrounding interest rate spreads, external financing conditions, and the future performance of risk premiums. The impact that this environment could have on the exchange rate and on domestic financing conditions represent risks to the macroeconomic and monetary policy forecasts. Domestic financial conditions continue to favor recovery in economic activity. The transmission of reductions to the policy interest rate on credit rates has been significant. The banking portfolio continues to recover amid circumstances that have affected both the supply and demand for loans, and in which some credit risks have materialized. Preferential and ordinary commercial interest rates have fallen to a similar degree as the benchmark interest rate. As is generally the case, this transmission has come at a slower pace for consumer credit rates, and has been further delayed in the case of mortgage rates. Commercial credit levels stabilized above pre-pandemic levels in March, following an increase resulting from significant liquidity requirements for businesses in the second quarter of 2020. The consumer credit portfolio continued to recover and has now surpassed February 2020 levels, though overall growth in the portfolio remains low. At the same time, portfolio projections and default indicators have increased, and credit establishment earnings have come down. Despite this, credit disbursements continue to recover and solvency indicators remain well above regulatory minimums. 1.2 Monetary policy decision In its meetings in March and April the BDBR left the benchmark interest rate unchanged at 1.75%.

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. Nevertheless, there are significant gaps in the evidence about the program components that are required to implement an effective LDCT screening program (Q3). Questions about LDCT screening acceptability and feasibility were not explicitly included in the scope. However, as the evidence is based primarily on US programs and UK pilot studies, the relevance to the local setting requires careful consideration. The Queensland Lung Cancer Screening Study provides feasibility data about clinical aspects of LDCT screening but little about program design. The International Lung Screening Trial is still in the recruitment phase and findings are not yet available for inclusion in this Evidence Check. The Australian Population Based Screening Framework was developed to “inform decision-makers on the key issues to be considered when assessing potential screening programs in Australia”.(10) As the Framework is specific to population-based, rather than high-risk, screening programs, there is a lack of clarity about transferability of criteria. However, the Framework criteria do stipulate that a screening program must be acceptable to “important subgroups such as target participants who are from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, people from disadvantaged groups and people with a disability”.(10) An extensive search of the literature highlighted that there is very little information about the acceptability of LDCT screening to these population groups in Australia. Yet they are part of the high-risk population.(10) There are also considerable gaps in the evidence about the cost-effectiveness of LDCT screening in different settings, including Australia. The evidence base in this area is rapidly evolving and is likely to include new data from the NELSON trial and incorporate data about the costs of targeted- and immuno-therapies as these treatments become more widely available in Australia.