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Background Health Literacy (HL) is the knowledge and competence to access, understand, appraise, and apply health information for health judgment. We analyze for the first time HL level of Catalonia’s population. Our objective was to assess HL of population in our area and to identify social determinants of HL in order to improve the strategies of the Healthcare Plan, aimed at establishing a person-centered system and reducing social inequalities in health. Methods This was a cross-sectional study based on the Health Survey for Catalonia (ESCA, Enquesta de Salut de Catalunya ), which included the 16 items of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). The statements in the questionnaire cover three different health literacy domains: Health Care, Disease Prevention, and Health Promotion. HL was categorized in three levels: Sufficient, Problematic and Inadequate. Chi-square tests were performed to compare the percentages of subjects with adequate or inadequate HL across sociodemographic and health-related variables. Variables showing significant differences were included in a stepwise logistic regression to predict inadequate HL level. Results The questionnaire was administered to 2433 subjects aged between 15 and 98 years old (mean of 45.9 years, SD 18.0). Overall, 2059 subjects (84.6%) showed sufficient HL, 250 (10.3%) inadequate HL, and 124 (5.1%) problematic HL, with no significant differences between men and women ( p  = 0.070). A logistic regression analysis showed that low health literacy is associated with a lower level of education (OR 2.08, CI 95% 1.32–3.28, p  = 0.002), low socioeconomic status (OR 2.11, CI 95% 1.42–3.15, p  <  0.001) and a physical limitation to perform everyday activities (OR 2.50, CI 95% 1.34–4.66, p  = 0.004). We also found a more modest association with low physical activity, having a self-perceived chronic disorder and performing preventive activities. Conclusions Catalonia has a high percentage of subjects with sufficient HL. Education level, socioeconomic status and physical limitations were the factors with the strongest contribution to inadequate or problematic health literacy. Although these results are likely to be country-specific, the factors identified will allow policymakers of areas with similar socioeconomic profiles to identify groups with high risk of problematic or inadequate HL, which is essential for a successful patient-centered model of care.

External validation is crucial in developing reliable machine learning models. This study aimed to validate three novel indices—Thermographic Joint Inflammation Score (ThermoJIS), Thermographic Disease Activity Index (ThermoDAI), and Thermographic Disease Activity Index-C-reactive protein (ThermoDAI-CRP)—based on hand thermography and machine learning to assess joint inflammation and disease activity in rheumatoid arthritis (RA) patients. A 12-week prospective observational study was conducted with 77 RA patients recruited from rheumatology departments of three hospitals. During routine care visits, indices were obtained at baseline and week 12 visits using a pre-trained machine learning model. The performance of these indices was assessed cross-sectionally and longitudinally using correlation coefficients, the area under the receiver operating curve (AUROC), sensitivity, specificity, and positive and negative predictive values. ThermoDAI and ThermoDAI-CRP correlated with CDAI, SDAI, and DAS28-CRP cross-sectionally (ρ = 0.81; ρ = 0.83; ρ = 0.78) and longitudinally (ρ = 0.55; ρ = 0.61; ρ = 0.60), all p < 0.001. ThermoDAI and ThermoDAI-CRP also outperformed Patient Global Assessment (PGA) and PGA + C-reactive protein (CRP) in detecting changes in 28-swollen joint counts (SJC28). ThermoJIS had an AUROC of 0.67 (95% CI, 0.58 to 0.76) for detecting patients with swollen joints and effectively identified patients transitioning from SJC28 > 1 at baseline visit to SJC28 ≤ 1 at week 12 visit. These results support the effectiveness of ThermoJIS in assessing joint inflammation, as well as ThermoDAI and ThermoDAI-CRP in evaluating disease activity in RA patients.

To describe the overall sleep health of the Catalan population using data from the 2015 Catalan Health Survey and to compare the performance of two sleep health indicators: sleep duration and a 5-dimension sleep scale (SATED). Multistage probability sampling representative of the non-institutionalized population aged 15 or more years, stratified by age, gender and municipality size, was used, excluding nightshift-workers. A total of 4385 surveys were included in the analyses. Associations between sleep health and the number of reported chronic diseases were assessed using non-parametric smoothed splines. Differences in the predictive ability of age-adjusted logistic regression models of self-rated health status were assessed. Multinomial logistic regression models were used to assess SATED determinants. Overall mean (SD) sleep duration was 7.18 (1.16) hours; and SATED score 7.91 (2.17) (range 0-10), lower (worse) scores were associated with increasing age and female sex. Alertness and efficiency were the most frequently impaired dimensions across age groups. SATED performed better than sleep duration when assessing self-rated health status (area under the curve = 0.856 vs. 0.798; p-value <0.001), and had a linear relationship with the number of reported chronic diseases, while the sleep duration relationship was u-shaped. Sleep health in Catalonia is associated with age and gender. SATED has some advantaged compared to sleep duration assessment, as it relates linearly to health indicators, has a stronger association with self-rated health status, and provides a more comprehensive assessment of sleep health. Therefore, the inclusion of multi-dimensional sleep health assessment tools in national surveys should be considered.

Background The EQ-5D has been frequently used in national health surveys. This study is a head-to-head comparison to assess how expanding the number of levels from three (EQ-5D-3L) to five in the new EQ-5D-5L version has improved its distribution, discriminatory power, and validity in the general population. Methods A representative sample ( N  = 7554) from the Catalan Health Interview Survey 2011–2012, aged ≥18, answered both EQ-5D versions, and we evaluated the response redistribution and inconsistencies between them. To assess validity of this redistribution, we calculated the mean of the Visual Analogue Scale (VAS), which measures perceived health. The discriminatory power was examined with Shannon Indices, calculated for each dimension separately. Spanish preference value sets were applied to obtain utility indices, examining their distribution with statistics of central tendency and dispersion. We estimated the proportion of individuals reporting the best health state in EQ-5D-5L and EQ-5D-3L within groups of specific chronic conditions and their VAS mean. Results A very small reduction in the percentage of individuals with the best health state was observed, from 61.8% in EQ-5D-3L to 60.8% in EQ-5D-5L. In contrast, a large proportion of individuals reporting extreme problems in the 3 L version moved to severe problems (level 4) in the 5 L version, particularly for pain/discomfort (75.5%) and anxiety/depression (66.4%). The average proportion of inconsistencies was 0.9%. The pattern of the perceived health VAS mean confirmed the hypothesis established a priori, supporting the validity of the observed redistribution. Shannon index showed that absolute informativity was higher in the 5 L version for all dimensions. The means (SD) of the Spanish EQ-5D-3L and EQ-5D-5L indices were 0.87 (0.25) and 0.89 (0.22). The proportion of individuals with the best health state within each specific chronic condition was very similar, regardless of the EQ-5D version (≤ 30% in half of the 28 chronic conditions). Conclusion Although the proportion of individuals with the best possible health state is still very high, our findings support that the increase of levels provided by the EQ-5D-5L contributed to the validity and discriminatory power of this new version to measure health in general population, as in the national health surveys.

Interlocus gene conversion is a major evolutionary force that drives the concerted evolution of duplicated genomic regions. Theoretical models successfully have addressed the effects of interlocus gene conversion and the importance of crossover in the evolutionary fate of gene families and duplications but have not considered complex recombination scenarios, such as the presence of hotspots. To study the interplay between interlocus gene conversion and crossover, we have developed a forward-time simulator that allows the exploration of a wide range of interlocus gene conversion rates under different crossover models. Using it, we have analyzed patterns of nucleotide variation and linkage disequilibrium within and between duplicate regions, focusing on a neutral scenario with constant population size and validating our results with the existing theoretical models. We show that the interaction of gene conversion and crossover is nontrivial and that the location of crossover junctions is a fundamental determinant of levels of variation and linkage disequilibrium in duplicated regions. We also show that if crossover activity between duplications is strong enough, recurrent interlocus gene conversion events can break linkage disequilibrium within duplicates. Given the complex nature of interlocus gene conversion and crossover, we provide a framework to explore their interplay to help increase knowledge on molecular evolution within segmental duplications under more complex scenarios, such as demographic changes or natural selection.

Introduction: Catalonia’s Department of Health is defining a new Strategy of integrated care for people with chronic conditions. The principles of person-centered care that inform the strategy highlight the relevance of empowering people. Accordingly, the participative project launched by Department of Health is aimed at capturing people’s needs, preferences and valuese. 9 discussion groups, roughly 100 people with chronic conditions, caregivers and healthy people took place in seven cities around the country. The identified topics on the desirable characteristics of care will be included in the definition of the Strategy. Objective: To reflect the views of people on healthcare services, their preferences, values and needs for integrated services in order to include them in the construction and codesign of an updated Chronic and Integrated Care model Methodology: Exploratory qualitative study with focus groups. Group interviews were audio recorded and digitally transcribed, and thematic content analysis followed. Emergent themes and subthemes were confirmed on an iterative process. To capture the diversity around the topic of interest, selection procedure of participants was based on chronic disease experience, with 4 distinctive profiles: 1. People with chronic conditions and complex needs; 2. People caring for people with chronic diseases or included in home care programmes; 3. People with non-complex chronic diseases; 4. Healthy people. Selection of individuals using snowball sampling method, with sociodemographic, socioeconomic and territorial quota. Healthcare professionals, managers and the Patients' Consultative Council of Catalonia nominate the participants. 96 people took part in the study and 89,6% answered a survey. No sex difference. 50% were retired and 47% had higher education. 21% lived in Barcelona. Conclusions: Focus groups allow in-depth analysis of specific topics, as it includes preferences, values and past experiences. Regarding healthcare of people with chronic conditions, some of the most valued issues identified are: Professionals with communicative and relational skills, who know how to manage the emotional dimension of chronic disease and the whole process of care. Reponse should be rapid, with different levels of expertise and speed. It is particularly valued direct, fast and trustworthy access to professionals. Accompaniment in transitions between services appear in integrated care environments. A much more bio-psycho-social oriented care is required, including healthcare and emotional management and taking into account social and family environment of people. Regarding health promotion, professionals should know much better their community asset maps and should be able to prescribe community resources. It is required to promote, from the health system and at community level, actions to break isolation and empower people when dealing with illness and caregiving tasks. End of life care and palliative specific resources are highly valued (listening, accompaniment, relational skills, integrated approach).(1) To include people’s views is a useful and valuable resource when defining strategies on chronic conditions help but also to assess their implementation. References: 1-  Gómez-Batiste X, Blay C, Martínez-Muñoz M. The Catalonia WHO Demonstration Project of Palliative Care: Results at 25 Years (1990-2015). J Pain Symptom Manage. 2016 Jul;52(1):92-9.

Although sleep habits have long been recognized as a promoter of health, the World Health Organization 2014 report on non-communicable diseases (NCDs) only listed smoking, alcohol intake, diet and physical activity (PA) as key modifiable risk factors that could enhance health and prevent NCDs. Cross-sectional data on 4385 surveys from the 2015 Catalan Health Survey, representative of the 2015 non-institutionalized Catalan population over age 14, were used to assess and compare the independent associations of low PA (International Physical Activity Questionnaire (IPAQ): low activity); poor diet (PREvención con DIeta MEDiterránea questionnaire (PREDIMED): low-adherent); poor sleep health (Satisfaction, Alertness, Timing, Efficiency and Duration scale (SATED): <8); smoking status; and, alcohol intake (high-risk drinker based on standard drink units) with having a poor self-perceived health status. Logistic regression models adjusted by age, gender, education level and number of comorbidities showed that poor sleep health had the strongest independent association with poor self-perceived health status (OR = 1.70; 95%CI: 1.37–2.12), followed by poor diet (OR = 1.37; 95%CI: 1.10–1.72) and low PA (OR = 1.31; 95%CI: 1.01–1.69). This suggests that sleep habits should be included among the important modifiable health risk factors and be considered a key component of a healthy lifestyle.

This dissertation employs computational methods to address concepts of economic dynamics, statistical equilibrium and economic disequilibrium, complex emergence, and input-output analysis in relation to economic topics of firm and multi-sector growth, structural change, technological innovation, and uneven development from the critical perspective of classical political economy. The first chapter contributes a statistical approach to Anwar Shaikh’s theory of real competition within a single industry, which is disaggregated by firms under alternative micro-foundations on classical-evolutionary lines, with the aim of extending it to a multi-sector framework. Contra the neoclassical view, it is shown that individual optimization (as in utility or profit maximization) is not necessary to reproduce a relevant variety of stylized facts of economic competition and thus can be theoretically dispensed. Economic equilibrium is re-conceptualized in conversation with the literature in econo-physics as an emergent, macro-level outcome of economic competition in the form of stable statistical distributions of micro-economic variables, instead of the conventional notion as a mechanical single-point, rest state. The second chapter makes a contribution to ecological economics by employing an extension with technological dynamics of the Flaschel-Semmler deterministic classical model of multi-sector growth in order to investigate the speed of the dynamic substitution of carbon sectors by green sectors under directed technical change. The model relies on the cross-dual adjustment between prices and quantities with respect to supply-demand and revenue-cost imbalances in the form of the laws of excess demand and excess profitability and is calibrated using standard OLS regressions on EU KLEMS and WIOD data. Fiscal policy, especially when the carbon tax is accompanied by a green subsidy, greatly accelerates the phase-in of the green sector, with the largest impact at its earliest stages. Without fiscal policy, it is impossible for any economy to reach the IPCC targets in time. The third chapter provides a literature review of how different theories of trade approach the issue of uneven development and empirically addresses it by applying the machine-learning method of Gaussian mixture modeling on Italy as a case study in economic integration. The analysis of the complex statistical structure of Italian regional inequality corroborates that it is most importantly characterized by a marked dual polarization into North and South as core and periphery, while revealing a more nuanced bi-modal/tri-modal division. Regional rates of gross value added follow a Laplace distribution, while the distributions of sectoral compensation and gross value added follow a power law. After 160 years of political and monetary unification, there is no evidence for any convergence of Italian regions in most of the data.

The aim of this study was to assess nailfold capillaroscopic (NC) findings in patients with primary Sjögren’s syndrome (PSS) with and without Raynaud’s phenomenon (RP) as well as in the presence of positive anti-SSA/Ro and anti-SSB/La antibodies. Videocapillaroscopy was performed in 150 patients with PSS. Data collected included demographics, presence of RP, PSS symptoms, antinuclear antibodies, rheumatoid factor, anti-Ro, anti-La, anti-CCP, salivary scintigraphy, labial biopsy, and NC findings. RP was present in 32 % of PSS, keratoconjunctivitis sicca in 91 %, oral xerosis in 93 %, and skin or genital xerosis in 53 %. In patients with positive anti-SSA/Ro (75 %) and positive anti-SSB/La (40 %), NC showed normal findings in 53 % of cases and non-specific in 36 %. In patients with PSS, NC was normal in 51 % of cases and non-specific in 34 %. Scleroderma pattern was found in 14 patients. RP associated with PSS had non-specific capillaroscopy in 40 % of cases ( p  = 0.1). Pericapillary haemorrhages ( p  = 0.06) and capillary thrombosis ( p  = 0.2) were not increased, but more dilated capillaries were detected in 48 % of cases. Patients with positive anti-Ro and/or anti-La have not a distinct NC profile. Patients with RP associated with PSS had more dilated capillaries, but neither pericapillary haemorrhages nor capillary thrombosis was observed.

Introduction: The World Health Organisation describes health literacy as the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health literate individuals have skills to keep healthier by themselves and to maintain their quality of life for longer. In ageing societies, where chronic conditions are expected to keep growing while resources will remain stable, health literacy is one of the keys challenges facing community health at the beginning of the XXI century.The Health Plan for Catalonia (HPC) is the indicative instrument and framework for all public programs in the field of the Health Ministry of the Government of Catalonia. The main 2020 goal of the HPC is to increase healthy life expectancy, that is, the proportion of years with a good self-perceived health status. This objective aligns with the purpose of promoting more health literate societies.Methods: During 2014 the health survey for Catalonia (HSC) included the short version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). HSC is an official survey that provides information on the health status, life styles and the use of health services of Catalonia’s population. 3.642 people aged 15 and over answered the questionnaire. HLS-EU-Q16 is a shortened version of the questionnaire HLS-EU-Q47, developed by the European Health Literacy Project 2009-2012, which was administered in eight different countries. As the longer version, HLS-EU-Q16 assumes a multidimensional concept of health literacy, which helps to identify health literacy profiles of individuals, but also of populations. A descriptive analysis of sociodemographic characteristics, health status and healht service use (% and CI95%) is performed according to the health literacy level of people.Results: Results show that the proportion of people with insufficient health literacy (either problematic or inadequate health literacy levels) is higher among people aged 65 and over, among people who attained primary education or below, and among people who belong to lower social classes. On the other hand, people without sufficient health literacy show worse perception of their health status, declare chronic conditions and have disabilities in a higher proportion than those who have sufficient health literacy levels. Regarding the use of health services, people with problematic or inadequate health literacy levels attend to the GP, consume medicines and go to the emergency department more frequently than people with sufficient health literacy.Discussion: The WHO global strategy on person-centred and integrated health care services establishes empowering and engaging individuals and communities as its first strategic goal. Promotion of health literacy is about providing resources and abilities to empower individuals and comunities but also about adapting health care systems to the needs of people. Results show that some people would face more difficulties than expected if they had to perfom health related activities. On the other hand, health literate people enjoy more autonomy when dealing with activities related to health information. In order to advance towards much more integrated and person-centred health care services, health literacy levels should be taken into account and promotion of health literacy at population, individual and health care serveices is desirable.Conclusion: Several difference arise in health status and health care service use arise according the health literacy level of people. These results are the starting point for designing the strategy on health literacy for Catalonia, which will help to design interventions aimed at strengthening and promoting health literacy, but also person-centred health care services.