Plague remains a public health concern worldwide, particularly in old foci. Multiple epidemics of this disease have been recorded throughout the history of Iran. Despite the long-standing history of human plague in Iran, it remains difficult to obtain an accurate overview of the history and current status of plague in Iran.In this review, available data and reports on cases and outbreaks of human plague in the past and present in Iran and in neighboring countries were collected, and information was compiled regarding when, where, and how many cases occurred.This paper considers the history of plague in Persia (the predecessor of today’s Iran) and has a brief review of plague in countries in the World Health Organization Eastern Mediterranean Region, including a range of countries in the Middle East and North Africa.Yersinia pestis has been reported among rodents and dogs in western Iran, more attention should be paid to disease monitoring in areas with previously reported human cases and in high-risk regions with previous epizootic and enzootic activity.Since Iran has experienced outbreaks of plague for several centuries, neighboring countries have reported the disease in recent years, the disease can be silent for decades, and the circulation of  Yersinia pestis, which was discovered in 1894 by Alexandre Yersin [Xenopsylla genus, in particular X. cheopis. Living in rural areas, hunting or trapping animals, and keeping cats and dogs increase the risk of infection among humans [Plague is a life-threatening infectious disease that is still endemic in some areas around the world. It is caused by the bacillus e Yersin ,3. The mg humans . The disY. pestis circulates at low levels in the rodent population in endemic foci of the disease [Y. pestis has also been used in bioterrorism in the past and its usage in the future for such purposes is not difficult to imagine [As  disease , outbrea disease ,6. Y. pe imagine . Studies imagine ,9, whichY. pestis has been reported throughout the world, and plague is enzootic in rodents in Africa, North and South America, and Asia  [There have been three great world pandemics of plague. The first one, known as the Justinian plague, occurred in the Byzantine Empire (Constantinople) in the 6th century Common Era (CE) and spread through the Middle East, the Mediterranean, and Europe. The second pandemic, known as the Black Death, began in India, China, and some regions of Russia, and reached Western Europe in 1347 CE. The third pandemic was the Hong Kong epidemic that started in 1855 CE in Yunnan Province, China ,4. Y. pet Union) ,10,11. At Union) .Some plague endemic foci still exist in central Asia; western Arabia (the Asir region); the Middle East, with a center in Iranian Kurdistan; central and southern Africa, and northwestern India -16. BetwPlague is one of the oldest infectious diseases in Iran, and has had devastating effects on the human population of Iran throughout history. Our understanding of plague pandemics has rapidly expanded in the last decade, largely due to molecular approaches, but much remains to be understood regarding past plague epidemics in various parts of the world, particularly in Iran, as Persia was the greatest empire in the Middle East for much of its history.The region of Kurdistan, north of the Zagros Mountains in Iran and stretching across southern Turkey and the north of Iraq and Syria, is considered one of the most significant endemic foci of plague worldwide -25.This review considers the history of plague in Persia (the predecessor of today’s Iran) and incorporates a brief review of the countries in the WHO Eastern Mediterranean Region, consisting of several countries in the Middle East and North Africa that have frequently experienced plague outbreaks in recent decades, including Afghanistan, Bahrain, Iraq, Jordan, Kuwait, Lebanon, Saudi Arabia, Syria, United Arab Emirates, Yemen, Egypt, Libya, Morocco, and Tunisia.Historically, the territory of the Persian Empire encompassed all of today’s Iran, Iraq, Lebanon, Jordan, Armenia, Turkey, and Syria, as well as parts of Saudi Arabia, Afghanistan, Pakistan, the Caucasus, Central Asia, and Egypt.2 , Iran ranks eighteenth in size among the countries of the world. Iran has a variable arid climate, in which most of the relatively scant annual precipitation falls between October and April. Seven percent of the country is forested.Iran is a Middle Eastern country, located south of the Caspian Sea and north of the Persian Gulf and Gulf of Oman. It shares borders with Iraq, Turkey, Azerbaijan, Turkmenistan, Armenia, Afghanistan, and Pakistan. With an area of 1,648,000 kmHistorical records show that plague has been active in Iran for centuries; however, insufficient information, invalid documentation, the misclassification of plague as a different infectious disease such as cholera, and the way in which plague has interacted with social dynamics have hindered the analysis of plague outbreaks over time.Plague frequently recurred in Iran throughout history, but the dating and characterization of the nature of plague outbreaks remain imprecise. The rapid expansion of plague with high mortality rates may have been related to sparse treatment centers, a poor public health system, the absence of effective quarantine arrangements, washing the dead bodies in rivers before burial, and transferring corpses to sacred places such as Mashhad, Qom, Najaf, and Karbala . Plague In 543 CE, plague reached what is now modern Iran after passing from Italy to Syria, Palestine, and Iraq, and infected the Persian imperial army and the population at that time . In 544 Kitāb al-Malakiyy. Abu Sahl ‘Isa ibn Yahya al-Masihi al-Jorjani (960-1000 CE) wrote an article about plague; and, interestingly, the Canon of Medicine of Avicenna (980-1037 CE) noted the clinical signs of bubonic plague and Esmail Jorjani (1042-1137 CE) mentioned inguinal lymphadenopathy as a sign of bubonic plague [To the best of our knowledge, no concrete documentation exists of plague outbreaks and the impact of the plague on Persia between 689 and 1270 CE; it seems, though, that plague continued to spread throughout Persia, remaining endemic after the outbreaks of 689 until the middle of the thirteenth century. Ali ibn al-Abbas al-Majusi (933-1000 CE) described plague in his medical book titled c plague .The Travels of Marco Polo, he mentioned that the city gates were closed due to the plague [Marco Polo, the famous Italian merchant traveler, reached the city of Tabriz, in northwestern Iran, in 1270 and in e plague .Several outbreaks of human plague occurred during the Safavid period (1495-1735 CE), affecting areas in northern Iran such as Gilan, Tabriz, Qazvin, and Ardabil. Another outbreak occurred in Qom, another city in the north, which continued for five years with 12,000 deaths. After the collapse of the Safavid Dynasty and the occupation of Iran by Afghan invaders, another plague outbreak was recorded in Gilan in 1727 CE. In 1731 CE, approximately 20,000 people died due to a plague outbreak in Hamadan and the western region of Iran .In the epidemics of 1772-1773 CE in Iran, quarantine practices were introduced into the Persian Gulf region for first time . This ouIn 1800, a plague outbreak started in the city of Mosul, northern Iraq, and spread to Baghdad and Istanbul. The authorities introduced quarantine measures to prevent the spread of the plague to India. During this wave, the workers of the British East India Company were moved to a village outside Basra. This led to no reports of plague among European residents .In 1830, an epidemic of plague affected the entire Persian Gulf region. The disease began in the fall of 1830 with an outbreak in Tabriz, northern Iran, which led to the death of 30,000 people and the relocation of the Iranian capital from Tabriz to Ardabil ,38. In 1A plague epidemic in western Iran, in the Kurdistan, Kermanshah, and Hamadan regions, led to thousands of deaths from 1829 to 1835 and in 1870 . In 1876Mohammad Razi Tabatabai, the senior physician of the army during the reign of King Naser al-Din Shah Qajar wrote a book on plague in 1875, in which he described the medical practices of the time and discussed control strategies for plague . BetweenA plague epidemic in a village north of Sabzevar, Khorasan Province in northwest Iran killed 37 individuals in 1877 . AnotherIn 1877, an epidemic of the disease was again reported in the cities of Rasht, Bushehr, and Kermanshah. Following that, a devastating epidemic occurred in the regions around the Persian Gulf; as a result, British forces founded the first quarantine center on Hengam Island, Bushehr, to prevent further transmission of the disease to other points of the country .The plague epidemic in 1906 in the province of Sistan and Baluchestan, southeastern Iran, was restricted to the regions around Sistan Lake, and it is believed that the infection was transmitted to this area via old clothes imported from India .During the plague epidemics between 1910 and 1911 in Bushehr, in southern Iran, people fled the city, leading to a negative economic impact . In 1912In 1913, outbreaks were seen in two provinces in Iran: one in Kurdistan in the west, and the other in Khorasan, in the east . A plaguSome of the plague outbreaks occurred in the area where the Anglo-Persian Oil Company, an English company, was actively extracting petroleum in the southern part of the country. The measures that were taken by this company had a great impact on the control of plague in the area. In 1925, plague vaccination started in the southern areas of Iran and 4,553 individuals were vaccinated. Houses were disinfected and with any new report of the disease, serious actions were taken, such as disinfection of all clothing, isolation of the patient, destruction of the house (with recompense), and prohibition of rebuilding on that spot .Meriones genus, including M. libycus, M. persicus, M. vinogradovi, M. tristrami, plays an important role in the persistence of plague. The latter two species are extremely sensitive to the causative agent of the disease, whereas the first two are resistant. The presence of plague in Kurdistan thus depends on the ecological interplay between susceptible and resistant rodent species living in close contact. Along with these species, other types of rodents are present, such as Microtus, Mesocricetus, Allactaga and Cristolus; these rodents are less frequently found and play a minor role in the epizootic evolution of the region [Plague was not reported again for 23 years until an outbreak in Kurdistan, western Iran, in 1947 . Due to e region . In 1953e region  concludePulex irritans, starting with rare cases of plague contracted in the fields. Such instances of inter-human transmission of plague, originating in villages, tend to die out rapidly due to the sparse population of the villages, the long distances between them, and the paucity of means of communication. However, when imported into an urban area with a denser human population, plague can immediately become the terrifying disease it was during the Middle Ages [Marcel Baltazard, the former director of the Pasteur Institute of Iran, and his Iranian colleagues studied 14,102 rodents in this region in 1966 and 1967, and found 66 infected rodents . During dle Ages . The lasdle Ages .Y. pestis could remain alive for several years in the burrows of dead rodents, and then re-infect the new rodents colonizing these empty burrows. In addition to the well-established rodent-flea-rodent cycle, they demonstrated the existence of the burrow-rodent-burrow cycle, allowing the inter-epizootic maintenance of the plague bacillus in its endemic foci [A major discovery resulting from the studies of these researchers in Kurdistan was the concept of burrowing plague . It was mic foci .Y. pestis were isolated from wild rodents  and from their fleas (Xenopsylla conformis and Nosopsylla iranus iranus) [The surveillance of regions surrounding the plague focus in Kurdistan, involving the study of wild rodents, revealed the existence of an epizootic center in Sarab in eastern Azerbaijan Province, north of Kurdistan, where plague had not yet been reported . In this iranus) .The surveillance of plague in Kurdistan by the Pasteur Institute of Iran revealed that the disease remained silent for a period of between three to five years in its natural foci and then reappeared in its rodent hosts ,54,55. TY. pestis infections were observed in the 1,800 rodents and 36,000 fleas monitored [The monitoring of plague continued from 1978 to 2001 through the Research Center for Emerging and Reemerging Infectious Diseases, located in Akanlu village in Hamadan. It concentrated on monitoring the disease in rodents, and positive rodents and/or fleas were identified. According to studies of the Pasteur Institute of Iran surveillance team during the Iran-Iraq war (1980-1988), in the areas affected by war, no onitored .A recent study in 2011 and 2012, conducted at the Research Center for Emerging and Reemerging Infectious Diseases (Akanlu), of the border area between Kurdistan and Hamadan provinces showed that 1.02% of the rodent population and 3.42% of dogs were positive for the antibody against the bacteria, implying that this focus is still active .Y. pestis are difficult to characterize. Using molecular biology technology on the few available strains from Iran and Kurdistan revealed that all isolates belonged to the Medievalis biovar [Y. pestis in Iran and its neighboring countries will hopefully supply strong evidence to fill the gaps on how the bacterium entered and circulated in Persia (Iran), and which biovar and genotypes of Y. pestis affected this region.Because most cases of plague outbreaks occurred before the emergence of microbiology, both the history and the historical population structure of s biovar , indicats biovar ,61, the s biovar ,63 and sIt is clear that plague frequently recurred in the Middle East and North Africa for over half a millennium, but the dating and the characterization of the nature of the plague outbreaks are fairly imprecise. Nevertheless, an attempt has been made to describe the periodicity and nature of recurrences of plague. The rapidity and the severity of these outbreaks raise the question of the endemicity of plague in this region.Roughly over the past century, plague outbreaks have been seen in at least 14 countries in the WHO Eastern Mediterranean Region in the Middle East and North Africa ; all of The WHO Expert Committee on Plague determined plague to be endemic in Afghanistan in its report in 1953 . EnzootiIn 1529 CE, an outbreak of plague occurred in Bahrain; leading to the failure of a Portuguese attack on this region. A plague epidemic in the Arabian littoral also affected Bahrain in 1773 ,67,68. Fal-Ashraf (the Notables) was recorded in Iraq and Syria [Throughout its history, Iraq has experienced multiple epidemics of plague . In 716 nd Syria . In an end Syria ,71. A plnd Syria . From 19nd Syria ,72.Plague in Jordan was first seen in the seventh century . In 1997The plague outbreak of 1773 CE in Iraq spread to Kuwait, leading to an outbreak in this region .This country has been affected by plague in a variety of ways over the ages and has played a significant role in transmitting the disease to other parts of the world. The plague epidemic in Marseille, France, in 1720 led to 50,000 deaths and occurred via transmission of the infection by a ship from Lebanon . In 1900This country has experienced several outbreaks of plague in the past . An outbThe circulation of plague among Syria, Palestine, and Egypt occurred regularly throughout history ,78. AccoIn 1914 and 1924, imported cases of plague were reported in Dubai .Y. pestis confirmed the nature of this outbreak in 1969.The oldest recorded case of human plague in Yemen occurred near the border with Saudi Arabia, in Asir Province, in 1815, and is believed to have spread to Jeddah and Mecca . The isoArvicanthis niloticus, and ectoparasites in combination with trade with Asia, Africa, and the Mediterranean, as well as the Nile floods, suggests that it is possible that Y. pestis was primarily a disease of the Nile rat, indicating that Egypt may have been the most probable point of origin of bubonic plague as an epidemic disease [In 1347 CE, plague reached Alexandria in Egypt, most likely through the port’s trade with Constantinople and ports on the Black Sea . Between disease . In 1940 disease . The reeBetween 1913 and 1920, multiple outbreaks occurred in Libya, with the largest taking place in 1917 in Benghazi, where 1,449 people died of plague . Twelve The first plague cases reported in Morocco were in 1909 among 25 military stations in Casablanca. A severe epidemic with 8,000 to 10,000 deaths took place in 1911. Between 1940 and 1945, almost 5,400 cases were reported in Morocco in the regions of Chaouia, Agadir, Marrakech, Rabat, Doukkala, and Port Lyautey ,90. AnotPlague has not been very prevalent in Tunisia , althougAccording to the WHO Expert Committee on Plague (1959) , and fieAlmost all of the countries in the Middle East and North Africa have reported human plague outbreaks, although less focus has been placed on epidemics of plague in wildlife. In the last 50 years, human plague outbreaks have been reported in Saudi Arabia ,76, AfghY. pestis in Iran.The presence of exemplary studies on the wildlife population in Iran may be due to the existence of a research center founded in 1952 as part of the Pasteur Institute of Iran; at this center, extensive studies have been carried out on rodents and other animal hosts of Comprehensive studies of locations with historical records of human plague could help clarify the current status of the disease in this region. Otherwise, without adequate knowledge and preparation, human plague outbreaks are expected to continue.Y. pestis has been observed among rodents and dogs in western Iran, more attention should be paid to disease monitoring in areas with previously reported human cases and in high-risk regions with previous epizootic and enzootic activity. Plague should be more strongly emphasized in the medical education system in Iran. It is highly recommended that general practitioners and healthcare workers obtain adequate knowledge of the natural cycle of Y. pestis and the clinical signs of plague in order to help them identify the disease. Moreover, further studies are needed to better clarify the epidemiology of plague in Iran.The lack of reports of human plague over the past 50 years does not necessarily imply that the disease has not occurred among humans in Iran. Since Iran has experienced outbreaks of plague for several centuries, neighboring countries have reported the disease in recent years, the disease can be silent for decades, and the circulation of Finally, the following suggestions may be made to improve the surveillance of plague in Iran: 1) Health staff and practitioners in areas with prior outbreaks of plague, as well as in the eastern and western border areas of Iran, should be trained to be aware of this disease. 2) A standard protocol should be designed for preparing and dispatching suspected samples from all over the country to the Pasteur Institute of Iran. 3) Educational materials on plague in the form of pamphlets, seminars, and conferences concerning zoonotic diseases should be prepared and disseminated. 4) The Research Center for Emerging and Reemerging Diseases of the Pasteur Institute of Iran (Akanlu) should be equipped and empowered as the main center of surveillance, research, and education about plague and other emerging and reemerging diseases in Iran.


Physical Condition (2004), of the NursingOutcomes Classification (NOC) for its precise use in clinical practice. cross-culturally adapt to the Spanish context and make a new proposal for thenursing outcome, Physical Condition, was conducted and supported by theopinion of 26 experts. The data was obtained through an electronic form, anda quantitative analysis was conducted, using the SPSS software. a cross-cultural adaptation study and a proposal for the nursing outcome,Physical Condition, received agreement from 26experts, with a mean score greater than 7.6 for adequacy of the outcomedefinition and its indicators, and 8.5 for the relevance of the indicators.the version adapted to the Spanish context was obtained and the proposal ofthe outcome, Physical Condition were obtained. The results obtainedindicate a high level of adequacy and relevance, an instrument of greatutility in the clinic, and research was obtained to evaluate theinterventions directed to the improvement of the physical condition.the version adapted to the Spanish context and a new proposal for Thus a concept calledConsidering this, nurses, who work first hand with the population that suffers theeffects of an increase in sedentary lifestylehysical Condition Related to Health,Physical Condition (2004), and obtaining empiricalevidence of content validity and consensus of the proposed outcome, PhysicalCondition Related to Health, to be important because it is determinantthat an instrument adapted cross-culturally is adequately developed and validatedthrough the analysis of satisfactory psychometric propertiesPhysical condition (2004),is linked to the health field and is composed of 13 indicators related to the healthstatus of a person that can be assessed with a 5-point Likert scale, in which a «5»is the best possible score and a «1» is the worst possible scoreFinally, we considered that nurses rarely use objective measures to evaluate thePPhysical Condition(2004), of the 5th edition of the NOC, to the Spanish context andto make a consensus proposal by expert opinion of the nursing outcome,Physical Condition Related to Health.The objectives of this study were to cross-culturally adapt the nursing outcome,Physical Condition, and of its indicators, from the NOCclassification, 5th edition The study that was conducted was a cross-cultural adaptation of the nursing outcome,Thus, to achieve the objectives, the study was conducted in two different phases:Physical Condition, ofthe 5th Edition NOC, to the Spanish context.Phase 1. - Adaptation of the nursing outcome, The transcultural adaptation of the original version to the Spanish context wasconducted according the process described by Beaton et al.Physical Condition, were performed from the source language(English) to the target language (Spanish), obtaining two versions in Spanish, namedrespectively, translation 1 (T1) and translation 2 (T2). In this first stage, theresearchers and the translators compared both translations, and the discrepanciesthat arose were agreed upon. The translations were performed by two bilingualtranslators whose mother tongue was Spanish, and who had different professionalprofiles. Translator 1 was a health sciences and physical education professional,specifically, a graduate in psychology and a professional athlete with knowledgeabout the concepts that the measuring instrument evaluates. Translator 2 was agraduate professional in English studies, who had no knowledge of the concepts ofthe instrument, and was not related to health sciences or physical activity. 2)Synthesis of the translations: in this stage, starting from the two translationsinto Spanish (T1 and T2) and the original version, we made a synthesis of thesetranslations to obtain a common version called translation 12 (T12). 3) Backtranslation: starting from the T12 version, and without knowing or seeing theoriginal version, two translators translated the instrument into the originallanguage, to make sure that the translated version reflected the same indicatorscontained in the original version, resulting in two versions in English, calledback-translation 1 (RT1) and back-translation 2 (RT2). In the third stage, the twotranslators that produced the back translations, RT1 and RT2, were two people whosemother tongue was English and who did not have knowledge about the concepts exploredin the measuring instrument, nor were they trained in the health sciences or inphysical activity; in particular, they were graduates in English philology whoworked as teachers and researchers at the Catholic University of San Antonio deMurcia (Spain). 4) Expert Panel: At this stage, a panel of experts was created,consisting of all the translators who had prepared the different translations. Thegroup of experts consolidated all the versions of the measuring instrument, theoriginal version and each of the different translations , withtheir corresponding reports on the contributions of the translators, creating afinal consensus version in Spanish.1) Initial translation: first, two translations of the nursing outcome,Physical Condition, of the NOC 5th edition, basedon the opinion of experts.Phase 2 - New proposal of the revised version of the instrument for measuring thenursing outcome, Physical Condition Related toHealth, through the opinion of experts, to obtain theoretical evidenceof face, consensus and content validity. After the bibliographic search in differentdatabases  and the creationof a proposal of the definition of the nursing outcome, Physical ConditionRelated to Health, and of the main components detected in theliterature: cardiorespiratory capacity, musculoskeletal capacity, weight and bodycomposition, and motor capacityPhysical Condition Related to Health. The purpose of theform was explained to them in the e-mail, and they were asked to participatevoluntarily in the research study, as well as provided instructions for correctcompletion. The form was developed through the electronic application, Google Forms.In it, the experts had to evaluate, on a scale of 1 to 10, the suitability of theproposed definition, where 1 = not at all adequate, and 10 = totally adequate.Likewise, the experts also had to assess the relevance of the different proposedindicators of the outcome, Physical Condition Related to Health,with a scale from 1 to 10, where 1 = not relevant and 10 = very relevant, and thesuitability of the definition proposed for each indicator. They were also allowed toexpress, through an open question, any other personal contribution on the definitionof the outcome, and the relevance or suitability of the proposed indicators. On theother hand, in the last sections of the form, a question was included asking theexperts to indicate which indicator they considered as the gold standard among thoseproposed, if they considered it appropriate, and what others indicators of thePhysical Condition Related to Health were considered relevantbut not included in the proposed definition. The statistical analysis performed foreach definition was a calculation of the arithmetic mean of theadequacy variable. Thus, we were able to measure the level ofadequacy that the experts assigned to each definition, in which the higher the scoreobtained, the better adequacy, and vice versa. Likewise, the limits of thedistribution and variance were calculated to measure the degree of consensus; highvariance scores indicate a greater degree of discrepancy over the adequacy of thedefinitions, while low scores indicate a lower degree of discrepancy. For therelevance variable, the mean, variance, limits of thedistribution, frequency, and percentage were also calculated, according to thescores assigned by the experts to each proposed indicator. 2) Proposal of therevised version of the instrument for measuring the nursing outcome,Physical Condition, of the NOC 5th edition: according to thescores obtained from the group of experts that showed the high level of adequacy andrelevance, and starting from the consensus of the definition and of the indicatorsof the outcome under study, we proceeded to establish the indicators of the proposednursing outcome, called Physical Conditionrelated to health, as the gold standard indicator, carrying out anew proposal for the revised version of the nursing outcome, PhysicalCondition of the NOC 5th edition.The second phase of the investigation was composed of the stages described below. 1)Quantitative analysis of the definition of The software used for the statistical analysis of the data of both variables wasSPSS, version 24.The present study was approved by the Clinical Research Ethics Committee of theHospital Clínico Universitario Virgen de la Arrixaca, belonging to Health Area 1(Murcia-West).Physical Condition, ofthe NOC 5th edition, to the Spanish context.Phase 1. - Adaptation of the nursing outcome, PhysicalCondition of the NOC 5th edition, show the translated versions of saidoutcome that are detailed in The results obtained in the first phase of the study, that is, the cross-culturaladaptation to the Spanish context of the nursing outcome, Physical Condition, of the NOC 5th edition, basedon expert opinion.Phase 2. - New proposal of the revised version of the instrument for measuring thenursing outcome, Physical Condition Related to Health. The origin of the expertswho participated in the round of work shows the diversity of health and physicalactivity professionals, who teach, conduct research or provide direct care invarious centers and services of sports medicine, Chair in sports, and faculties ofhealth sciences , whocontributed their knowledge to this study. Likewise, the largest number of expertscame from the nursing faculty at the Facultad de Enfermería de la UniversidadCatólica San Antonio de Murcia, as presented in In the second phase of the study, 26 forms were obtained, duly completed, with theopinion of the selected experts on the definition of the proposed nursing outcome,Physical Condition Related toHealth, as well as in the indicators raised, representing a high levelof adequacy. However, although there were differences between the assigned scores,the variance had low values, as can be seen in The statistical analysis of the data showed that the scores obtained afterconsultation with the experts revealed mean scores above 7.6 in the adequacy of thedefinition of the proposed nursing outcome, In relation to the statistical analysis of the scores obtained for the relevance ofthe indicators of the proposed outcome, the average scores were above 8.15, whichindicates high relevance, and the variance was low, revealing low discrepancybetween the contributions of the experts . A majorPhysicalCondition Related to Health, the results obtained suggested theinclusion of these indicators: muscle elasticity, fat-freemass, mobility or range of motion, bodyfatpercentage, and speed of reaction, although all ofthem had a very low percentage (3.85% -11.54%). However, body fatpercentage was the indicator that had the highest score (11.54%)and was included in the proposal, due to its significance in the assessment ofphysical condition in the health fieldAs for other indicators suggested by the group of experts for cardiorespiratory capacity indicator was the one with thehighest assigned score (34.62%), therefore, since it is an essential component ofPhysical Condition Related to HealthRegarding the star indicator raised by the group of experts, thePhysicalCondition Related to Health, was developed and agreed to by 26 experts,comprised of seven indicators; this proposal is presented next to the originalversion, in As a final result of the study, the proposal of the nursing outcome, Physical Condition, (T1 and T2) by the selected translatorsfacilitated the conceptual, cultural, idiomatic, and semantic adaptation in theSpanish context by these translators, resulting in a final synthesized version ofEnglish to Spanish (T12). The following phases of back translationand synthesis of the back translations contributed to theverification of the suitability of the T12 version, thus allowing us to initiate thesecond stage of the investigation.The use of a measuring instrument in a clinical environment, different from the oneof origin, requires a process of cultural adaptation to verify semanticequivalencePhysical Condition, of the5th edition NOC classification, adapted to the Spanish context, and agreed upon byconsulting experts, the definition of the outcome, Physical ConditionRelated to Health, had a high level of adequacy for which saiddefinition was proposed for the revised nursing outcome, since the physicalcondition not only implies carrying out physical activities with vigorExpert judgment is a fundamental procedure that would beframed within the content validityIn the proposal of the nursing outcome, The changes made to the label, definition and indicators of the proposed version,with respect to the original version of the 5th Edition NOC, in English, indicatethat the original nursing outcome required revision for its precise use in theclinical setting, and in the Spanish context.Physical Condition, amodification has been made by introducing a more specific label to the area ofinterest and study, that is, Physical Condition Related to Health.The concept of physical condition related to health encompasses those components ofphysical condition that are linked to the health status of a person, and that may bedetermined by the performance of physical activity on a regular basisRegarding the label of the nursing outcome, PhysicalCondition, of the 5th edition NOC, this did not cover the totality ofthe set of aspects referred to by the concept of Physical Condition Relatedto Health, as it is a very brief and incomplete definition. Afterconsultation with the experts, the definition of the proposed version of theoutcome, Physical Condition Related to Health, was agreed upon anddeveloped to obtain a Spanish version adapted semantically and culturally from therevised nursing outcome: a set of biological qualities that allow people tocarry out their daily life activities with vigor and caution, without excessivefatigue and with enough energy to enjoy leisure activities and face unforeseenemergencies.In reference to the definition of the nursing outcome, -musclestrength and body mass index, as they are allcomponents of the physical condition in the health fieldperformance of physical activities, performance of routineexercise, physical conditioning, blood pressure, target heart rate duringexercise, and resting heart rate, since, although some authors,cardiovascular function andrespiratory function, were replaced bycardiorespiratory capacity component, waist-hipratio was replaced by waist circumference, andjoint flexibility was replaced by flexibility.Finally, we have included 2 new indicators that are balance andbodyfat percentage, since they are essential dimensions of the physicalcondition related to health -Mentioning the indicators of the nursing outcome studied, and according to theopinion of the experts consulted, since it is considered that the evaluation processconducted by a committee of experts on the content of the items demonstrates contentvalidity of the adapted instrument for the other culture The knowledge of the adult population’s state of physical condition is an importantindicator of health, and there is currently a deficit of instruments and studieswritten in Spanish that assess it-Physical Condition (2004), to the Spanish contextand the proposal of the outcome, Physical Condition Related toHealth, validated conceptually, through the opinion of a group ofexperts, it is a great contribution for its safe use in clinical practice, in theSpanish context.Currently there are few instruments that allow us to evaluate physical condition in asimple, economic, and accurate wayThe content validation evaluation analyzes the representativeness or adequacy of thecontent of the measuring instrumentPhysicalCondition (2004), of the 5th Edition NOC when being adaptedcross-culturally from the original English version, to the Spanish context,obtaining a version in Spanish language with the same semantic equivalences. It isconsidered that the conceptual validation of nursing outcomes is highly relevant forthe development of standardized nursing language, since it contributes to theimprovement of communication among nursing professionals, the application anddocumentation of the nursing process and the advancement of nursing knowledge.The study updated the existing knowledge on the nursing outcome, Physical Condition Related to Health,reflects the state of health studied in a more precise way, which will be able tofacilitate the systematized planning and implementation of nursing care for nurses.However, the importance of continuing the analysis of the rest of the psychometricproperties, in future studies, is highlighted.The proposed nursing outcome,


We live in a time of amazing speed in the production, diffusion and interconnection of knowledge. This rapid pace has transformed the way children think, learn, and interpret information. The school, a space for formal learning, takes a strong sociocultural and affective role in this context, particularly in Brazil, a country with so many inequalities. Thus, the role of using current teaching methods -, which allow for the improvement of skills, development of individualized and motivating teaching strategies and potentialities - also compensates for differences, reducing the inequality of opportunities. In this sense, it is key to strengthen and identify weaknesses early on, and to develop the confronting potential of the most vulnerable children. Hence the need for extensive interdisciplinary approaches to health and education professionals, both for the identification and selection of effective rehabilitation strategies in face of learning difficulties.It is estimated that around 15-20% of children at the beginning of schooling have difficulties in learning, and these estimates can reach 30 to 50% if the first six years of schooling are analyzed. Poor school performance, defined as a lower-than-expected academic achievement for a given age, cognitive abilities, and schooling, is complex and multifactorial. It includes Learning Difficulties related to multiple factors - such as low socioenvironmental opportunities and emotional conflicts - to Learning Disorders of a neurobiological nature - such as dyslexia, dyscalculia and Attention Deficit/Hyperactivity Disorder. Poor school performance, regardless of etiology, affects the various spheres of the child’s relational network, leading to emotional problems such as anxiety, low self-esteem, and demotivation.Recognizing how the child assesses their own performance and level of satisfaction with life starts with the metacognitive premise that the developing child is able to express themselves and access their subjectivity. The study “Quality of life and self-perception of health of children with poor school performance


Department of Health and Human Services, the task force is an independent, nonfederal, uncompensated panel of public health and prevention experts whose members are appointed by the Director of CDC. The task force provides information for a wide range of decision makers on programs, services, and policies aimed at improving population health. Although CDC provides administrative, research, and technical support for the task force, the recommendations developed are those of the task force and do not undergo review or approval by CDC.


Technological advancements rapidly propel the field of genome research. Advances in genetics and genomics such as the sequence of the human genome, the human haplotype map, open access databases, cheaper genotyping and chemical genomics, have transformed basic and translational biomedical research. Several projects in the field of genomic and personalized medicine have been conducted at the Center for Life Sciences in Nazarbayev University. The prioritized areas of research include: genomics of multifactorial diseases, cancer genomics, bioinformatics, genetics of infectious diseases and population genomics. At present, DNA-based risk assessment for common complex diseases, application of molecular signatures for cancer diagnosis and prognosis, genome-guided therapy, and dose selection of therapeutic drugs are the important issues in personalized medicine.To further develop genomic and biomedical projects at Center for Life Sciences, the development of bioinformatics research and infrastructure and the establishment of new collaborations in the field are essential.Widespread use of genetic tools will allow the identification of diseases before the onset of clinical symptoms, the individualization of drug treatment, and could induce individual behavioral changes on the basis of calculated disease risk. However, many challenges remain for the successful translation of genomic knowledge and technologies into health advances, such as medicines and diagnostics.It is important to integrate research and education in the fields of genomics, personalized medicine, and bioinformatics, which will be possible with opening of the new Medical Faculty at Nazarbayev University. People in practice and training need to be educated about the key concepts of genomics and engaged so they can effectively apply their knowledge in a matter that will bring the era of genomic medicine to patient care. This requires the development of well-equipped laboratories, bioinformatics, as well as qualified trained physicians and laboratory staff.


To improve the usability, availability, quality, and timeliness of surveillance data as part of the CDC Surveillance Strategy  strategy to streamline NNDSS and access to data for users; NMI is a component of the CDC Surveillance Strategy. This consolidation of information also is in response to the recommendations of a CDC-wide workgroup, consisting of representatives from the CDC Excellence in Science Committee, the Surveillance Science Advisory Group, and


Quaternary prevention consists in the identification of persons at risk of excessive medicalization and their protection against new unnecessary interventions, avoiding iatrogenic damages. Here, we argue about the importance of quaternary prevention in specific primary and secondary prevention. The recent great development of preventive medicine, biomedicalization of risks and their treatment as if they were diseases, and the powerful influence of the commercial interests of pharmaceutical industries on the production of medical-sanitary knowledge alter classifications, create diseases and pre-diseases, lower cutoff points, and erase the distinction between prevention and healing. This situation converts larger amounts of asymptomatic persons into sick individuals and diverts clinical attention and resources from sick persons to the healthy, from older adults to young persons, and from the poor to the rich. Quaternary prevention facilitates and induces the development and systematization of operational knowledge and guidelines to contain hypermedicalization and the damages of preventive actions in professional care, especially in primary health care. Quaternary prevention (P4) is a relatively recent concept (and practice), which means the identification of persons at risk of excessive medicalization and their protection from further unnecessary interventions, avoiding iatrogenic damages and proposing ethically acceptable measuresThe objective of this article is to present the relevance of P4 specifically for primary and secondary prevention activitiesPreventive behaviors have always existed and followed the history of health care and sickness practices in societies, including contemporary Western medicine or biomedicine. However, what we now call preventive medicine began in the first half of the twentieth century, having more presence in its second half. It consisted of a movement to construct a preventive attitude to influence medical professionals, who were then accused of focusing on curativistic actions, that is the diagnosis and cure of diseases. Preventive medicine was characterized by three premises: (1) focus on the individual and the family, (2) performed in the daily practice of physicians, (3) “represents a major transformation in the medical practice [...] and is based on the development of a new attitude by the physician” Arouca2, p.12.The fundamental theoretical basis of this movement was the model of the natural history of diseaseThe ‘natural history of diseases’ is a relative concept that should not be generalized today beyond some infectious diseases, since it was developed around them in the nineteenth century. Its reality is dubious even in many infectious processes  and also in lupus erythematosus, schizophrenia, diabetes, lumbar disc hernia, dementia, depression, and breast cancerIf the preventive medicine movement is not evaluated as successful in the twentieth century, today the incorporation of preventive actions in medical practice has advanced greatly, especially from the development of preventive pharmacological treatments, whose most famous example may be statins, for the reduction of cholesterol levelsQuaternary prevention focuses on all clinical and health activities, including other types of prevention. It concerns the necessary self-containment of this activity, now notoriously known to be a significant health riskLeavell and ClarkQuaternary prevention induces critical evaluation and reaction in physicians, health professionals, and professionals and managers of health systems about themselves and their activity, in an operational manner, including the questioning of their technical and ethical limits and the recognition of influences that affect decisions and preventive behaviors. It points to the construction of good practices, against cultural, technical, and institutional tendencies, which are sometimes harmful to individual and collective health. Unlike primary, secondary, and tertiary prevention, the objective of P4 is the action of professionals and health systems, especially primary health care (PHC) professionals, who have the same origin as P4primum non nocere”, it is relatively novel, since this principle has always referred to an ethics that was only spoken and generically proclaimed,Although P4 seems to repeat the old medicine principle “Quaternary prevention in prevention induces an organized discussion and a collective recognition of professionals and the health system about problematic situations, in which interventionist and overmedicalizing attitudes, potentially more harmful, are common, which demand guiding knowledge for containment and correction. This opens space for the construction of guidelines that need to be systematized to better protect users from the damages and risks produced by preventive clinical-health action.Among other factors, the therapeutic limits and the adverse effects of biomedicine for chronic diseases associated with their increasing costs and social and cultural changes that constitute a health paradox have paved the way for the emergence of a preventive change in biomedicine.Barski,The biomedicalization and management of prevention and treatment of isolated individual risks as chronic diseases operate within a cultural industry in which there is an obsessive search for present and future health, becoming a moral obligation, value, and fashion. It puts pressure on citizens to submit to biomedical knowledges, linked to the consumption of products, services, and technologies, in addition to holding them accountable for behavioral changes that are often difficult or even unfeasibleIn this context, the operational, conceptual, and methodological aspects of preventive medicine were made possible and driven by the great development of the production of knowledge centered on the notion of risk, especially the so-called clinical epidemiology or evidence-based medicine. This evidence-based medicine strongly diverted prevention to interventions on individuals and their risks. There was an intense “predominance of the individual over the collective, from the technical to the political, from the natural to the social, from the care physician to the sanitary physician, from the private to the public” Ayres3, p.236The identification (and treatment) of risk factors as part of prevention began a new era in public health, focused on individual intervention. The definitions of disease have been changing over time, becoming more inclusive, with lower diagnostic thresholds. In addition, risk factors are being managed in clinical practice as if they were diseases . In this process, the difference between prevention and cure is becoming increasingly blurredMedical practice in the twenty-first century has been changing, broadly incorporating preventive attitudes and actions. Individual preventive interventions are being disseminated, based on professional and institutional clinical decisions, especially in PHC. Preventive guidelines invade medical knowledge and practice, as well as clinical guidelines and institutional norms and regulationsIn the production of biomedical knowledge, the maneuvers to lower cutoff points for diagnoses of increased risk have intensified and legitimized this process. The expansion of the number of risk factors expands the area of action of preventive intervention, also expanding the number of potentially treatable situations. Specifically, this means the increasingly early biomedicalization and intervention in “pre-disease” states and risk factors, with ever more rigid and difficult-to-reach targets requiring the use of medications. This occurs, for example, with hypertension, hypercholesterolemia, obesity, and osteopenia. The consequent commercialization of drugs for asymptomatic persons substantially contributes with the expansion of these markets and increases polypharmacy, especially in older adults, generating increased iatrogenesis. In addition, it increases costs for society and health services. Finally, this increasingly common and present trend can reduce the quality of life by converting healthy persons into chronic patients,With the progressive elimination of the distinction between prevention and cure, the generation of pseudo-diseases and “pre-diseases”, and the medicalization of risks, preventive and therapeutic clinical demands are created for national health systems and medical practice, especially in PHC, being these demands largely not considered as medical problems in the past and mostly disconnected from the feeling of sickness. In addition, preventive actions have been indicated without adequate foundation, being accumulated in professional practices and, consequently, increasing the chance of iatrogenic damagesAs a psychological, cultural, and technical consequence, users  and professionals have progressively less tolerance to the oscillations and variations of the individual health and disease process. This lower tolerance produces demand and pressure for increasingly early interventions. Thus, we have a decrease in the margin of normality and an increase in the pathological and higher risk spectrum, this one managed as a disease. Therefore, more diagnoses and preventive actions are carried out, with complementary tests and drugs; and the interval of safety, the margin between benefits and risks, decreases. “Patients are increasingly being treated with a greater degree of diagnostic and therapeutic resources”  and quality of the evidences in relation to their final results, to evaluate the balance between its damages and benefitsQuaternary prevention in prevention induces the production, systematization, and collectivization of critical knowledge, strict technical criteria, and careful ethical requirements by guiding professional and institutional preventive actions. It can contribute to prevent the excessive medicalization of prevention and reduce its damages, several not being perceived by users and professionals.


To search in the scientific literature for nursing diagnoses identified in adult/elderly patients undergoing antineoplastic chemotherapy in an outpatient setting.Review of studies published in Portuguese, English, or Spanish which were searched in five electronic databases in March 2016, using the descriptors nursing process, nursing diagnosis, neoplasms, drug therapy and hospital outpatient clinic.In the four studies selected for review, 40 nursing diagnoses were identified, namely unbalanced nutrition, less than body requirements, risk of deficient fluid volume, diarrhoea, fatigue, impaired home maintenance, deficient knowledge, disturbed body image, interrupted family processes, ineffective sexuality pattern, anxiety, powerlessness, fear, readiness for enhanced religiosity, risk of infection, impaired dentition, risk of impaired skin integrity, acute pain, and nausea.The nursing diagnoses identified can support the selection of interventions and the creation of nursing guidelines in outpatient oncology services. The present study deals with the diagnostic stage of the nursing process. Defined as a clinical judgment based on the data collected in the nursing history, culminating in decision making about the diagnostic concepts that represent the responses of the person, family or community at a given moment in the health-disease process, nursing diagnosis (ND) is the basis for the selection of interventions aimed at achieving results for which the nurse is responsible .According to Resolution No. 358/2009 of the Federal Nursing Council, the disciplinary body for professional nursing practice in Brazil, the nursing process must be carried out deliberately and systematically in all public and private environments in which professional nursing care takes place. Therefore, it should be formally documented in order to highlight the contribution of nursing to the health care of the population and, consequently, to increase visibility and professional recognition [In oncology services, the nursing process is imperative due to the high frequency of physical and psychological damage that compromises patients’ quality of life . This isThe estimation for Brazil for the years 2016–2017  indicateGiven this estimate and knowing that cancer patients are frequently treated with antineoplastic outpatient chemotherapy, nurses working in oncology outpatient services should provide care with a focus on the individual’s needs, using the ND as a tool in the context of nursing process for selecting interventions with the goal of improving patients’ responses to the proposed antineoplastic treatment. Considering the lack of publications on ND in oncology and the fact that knowledge of common NDs in this area can strengthen the nursing process, in addition to providing oncology nurses with support for decision-making, choosing the best interventions, and performing a quality clinical practice, the objective of this study was to search in the scientific literature for NDs identified in adults/seniors undergoing antineoplastic chemotherapy in an outpatient setting.This is a review of the scientific literature which involved gathering, analysing and synthesising, in a systematic and orderly way, results of studies that investigated NDs in adults and seniors undergoing outpatient chemotherapy according to the following steps: formulation of the guiding question, search of the study literature, interpretation and synthesis of the evidence from the selected studies. The guiding question for this review was the following: Which nursing diagnoses have already been identified in adults/seniors undergoing anticancer chemotherapy in an outpatient setting?Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health (CINAHL), Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO), and Nursing Database (BDENF). As a search strategy, 12 different combinations of the descriptors were used: Nursing Process (Nursing Process), Nursing Diagnosis (Nursing Diagnosis), Neoplasms (Neoplasms), Chemotherapy (Drug Therapy) and Outpatients Clinics Hospital  .In March 2016, with no restrictions on the nature of the study or language, two authors independently searched for indexed studies in the electronic databases ospital) . The selNANDA International [The criteria for inclusion of studies in the review were as follows: be published in original article format in English, Spanish, or Portuguese; having as study subjects adult and/or elderly individuals undergoing antineoplastic chemotherapy on an outpatient basis and; the NDs being identified in this population, according to national  Taxonominational .5,941 studies were found in the MEDLINE database, in addition to 186 in CINAHL, 227 in LILACS 227, 152 in BDENF, and 17 in SciELO, for a total of 6,523 studies, which were then preselected from those with titles and abstracts which met the criteria explained previously. In the MEDLINE database, two studies were preselected, in CINAHL nine, in LILACS eight, in BDENF three, and SciELO none, for a total of 22 studies. After elimination of duplicates and reading of the studies in full, the final sample of studies selected for the present review consisted of four original papers . The refIn order to extract information from the articles selected for the review, a data collection form was developed in which all NDs identified by each of the selected articles were listed. The form also allowed us to obtain information on the authors, country, and year of publication of the article, with objectives, design, data source, sample type, conclusions and recommendations for nursing practice. The interpretation and synthesis of the evidence gathered from the selected articles was done in a descriptive manner, allowing the reader to understand each study included in the review, and considering the quality criteria established by nursing students .NANDA International [A summary of the main features of the articles included in the review is presented in national  Taxonominational , while aAs all studies selected for the review are descriptive, the low level of quality of the evidence generated by them is highlighted: level 6, on a scale of 1 to 7, where level 1 represents the highest quality Evidence .Of the 34 actual NDs and six risks identified, at least half of the component articles in the review described the following: unbalanced nutrition, less than body requirements, risk of deficient fluid volume, diarrhoea, fatigue, impaired home maintenance, deficient knowledge, disturbed body image, interrupted family processes, ineffective sexuality pattern, anxiety, powerlessness, fear, readiness for enhanced religiosity, risk of infection, impaired dentition, risk of impaired skin integrity, acute pain, and nausea .In order to provide an overview of the most common NDs in adults/seniors undergoing outpatient chemotherapy and thus to provide support for the decision-making of the oncology nurse during the completion of the nursing process, the present review identified 40 ND: 34 real and six at risk. Only in the growth/development domain, no NDs were identified, which was expected, as in this domain there are only NDs related to age-appropriate development (childhood and adolescence) .All articles selected have described the ND body image disorder, defined as confusion in the mental image of the physical self . AntineoOnly one selected article  did not The ND of anxiety was described by almost all the articles components of this review –8, 10. DAn experimental study that evaluated the effect of prayer on the anxiety of cancer patients in chemotherapy treatment  showed tDefined as a response to the perceived threat that is consciously recognised as a hazard, the ND Fear  was alsoIn view of this, it is important to note that anxiety and fear are among the defining characteristics of ND. Defined as a perception of lack of comfort, relief and transcendence in the physical, psychospiritual, environmental, cultural and/or social dimensions, the ND acute pain  was idenNausea and diarrhoea are frequent toxic effects caused by antineoplastic chemotherapy . DiarrhoNDs nausea and unbalanced nutrition: less than bodily needs have a defining characteristic in common, food aversion . A hypotIt is worth noted that diarrhoea is also one of the defining characteristics of unbalanced nutrition ND: less than body requirements . IncreasThe impaired dentition ND, defined as rupture in dental developmental/eruption patterns or structural integrity of each tooth , was ideA selected study  for thisPowerlessness is an ND that is defined by the lived experience of lack of control over a situation, including a perception that the actions themselves do not significantly affect a result . One of The ND Interrupted family process, defined as change in relationships and/or family functioning , was desThe ND pattern of ineffective sexuality, defined as an expression of concern about one’s own sexuality, was also described by two studies selected to compose the review , 9. ThesThe ND deficient knowledge, defined as absence or deficiency of cognitive information related to a specific topic , was ideIn the present review, six of the 40 nursing diagnoses identified were at risk. The fact that the majority of NDs are real indicates that nursing care for adults/seniors undergoing outpatient anticancer chemotherapy is focused on health recovery. On the other hand, the identification of risk NDs also suggests that nurses are concerned about preventive aspects of care.Defined as vulnerability to invasion and multiplication of pathogenic organisms, which may compromise health, risk of infection  was idenBoth ND risk of impaired skin integrity, defined as vulnerability to alteration in the epidermis and/or dermis, and ND deficient fluid volume, defined as vulnerability to decreased intravascular, interstitial and/or intracellular fluid, have pharmacological agents as a related risk factor . It is kAs all the studies selected for this review have a descriptive character, we must highlight the low level of the quality of the evidence generated by them . HoweverAmong the limitations of this review we point out the search and selection of studies in the form of a research article indexed in electronic databases only and the different characteristics of the populations of the studies that comprise it: two were conducted on women with breast cancer , one on Given the scarcity of publications on the diagnostic phase of the oncology nursing process, the 40 NDs identified by the present review point to the complexity of the care provided to patients undergoing chemotherapy in an outpatient setting. If used as a guide for the investigation of NDs among adult/elderly users of oncology outpatient services, the results of this review may contribute to the advancement and improvement of the nursing process.The authors declare that there are no conflicts of interest.RTJ participated in the design and outline of the article, bibliographic research, data analysis and interpretation, discussion of results, writing, and final approval of the article.RAFG participated in the bibliographic research, data analysis and interpretation, critical review, and final approval of the article.DCL participated in the bibliographic research, critical review, and final approval of the article.HFG, EMP, and EFPJ participated in the critical review and final approval of the article.


The Nursing area is increasingly faced with the challenge to prepare its professionals for the performance of technical and non-technical skills. In this sense, simulations, particularly high-fidelity ones, have been recognized as allies, with advantages for patient safety, teamwork, cost reduction in the real scenario and the handling of emotions of the learners. Herein, we are interested in considering the non-technical skills, whose relevance is based in knowing that a significant portion of the adverse events- The term non-technical skill, which comes from the aviation area in the '90s and is used in different areas, including health, refers to the cognitive and social skills and the personal resources that complement the technical skills and contribute to the safety and effective performance of tasks. Or, in the words of authors of the area of healthSuccessful teaching examples reinforce the use of simulations, in various scenarios and in varying degrees of complexity, as in nurse-patient communication development, interprofessional relations in critical situations or emergencies, teamwork, communication of bad news, ethical dilemmas, intra-team conflicts, management of stressful situations, leadership exercises, among others. Therefore, they point to development opportunities in the attitudinal, behavioral, ethical and moral fields. In addition to the clinical scenarios traditionally used in simulations for the development of non-technical skills, other forms of simulation, involving games or virtual environments, are mentioned in the literature. The contribution of Second LifeOne of the crucial points in the teaching or training of skills, especially non-technical ones, is their assessment. Models for this end have pointed to the use of indicators of (observable) behaviors. A recent review of the literatureSome of the currently known assessment tools in the area of health follow the recommendations of the European taxonomy of pilots' non-technical skills (NOTECHS)We highlight that both the instruments created for the medical area, which assess professional behaviors in anesthesia and surgery procedures or the perceptions of interactions between the team during surgery, among others, and those instruments created by nursing, which assess the clinical judgments of nurses, among others, are relevant and contribute for the assessment of non-technical skills in simulation situations, especially if accurate and composed of observable indicators.However, there is still a long way to go regarding the training and assessment of these skills in the context of large-scale events, such as accidents or natural disasters, in particular for the development of behaviors or skills of collaboration, negotiation and communicationThe familiarization with such a teaching technique and the tools to assess these skills, essential to the professional exercise, taking advantage of their potential, has been a challenge for the area of health, in particular nursing. It is up to trainers and institutions to both acknowledge such contributions and prepare themselves for their effective use.


In the published article, affiliations 1 and 2 were switched. Affiliation 1 should be: Department of Applied Microbiology and Biotechnology, School of Biotechnology, Yeungnam University, Gyeongsan, South Korea. Affiliation 2 should be: Department of Biotechnology, Daegu University, Gyeongsan, South Korea.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background: The Chilean health system has undergone profound reforms since 1990, while going through political upheaval and facing demographic, health, and economic transformations. The full information requirements to develop an evidence-informed process implied the best possible use of the available data, as well as efforts to improve information systems.Objective: To examine, from a historical perspective, the use of evidence during the health sector reforms undertaken in Chile from 1990 to date, and to identify the factors that have both determined improvements in the data and facilitated their use.Methods: A qualitative methodological approach was followed to review the Chilean experience with data on decision-making. We use as the primary source our first-hand experience as officials of the Ministry of Health (MOH) and the Ministry of Finance before and during the reform period considered. A literature review was also conducted, using documents from official sources, historical accounts, books, policy reports, and articles published in indexed journals reviewing and discussing the reform process, looking for the use of data.Results: The Chilean health-care reform process was intensive in its use and production of information. The MOH conducted several studies on the burden of disease, efficacy of interventions, cost-effectiveness, out-of-pocket payments, fiscal impact, social preferences, and other factors. Policy and prioritization frameworks developed by international agencies strongly influenced the use of data and the study’s agenda.Conclusions: The Chilean example provides evidence that tradition, receptiveness to foreign ideas, and benchmarking with international data determined the use of data, facilitated by the political influence of physicians and, later, other technocrats. Internationally comparable statistics are also shown to play a significant role in the policy debate. This article is a case study of the development in Chile of a culture of data use and evidence-informed policy-making over several decades, during which Chile went through many major political upheavals and faced demographic, health, and economic transformations. The article examines the use of evidence during the health sector reforms undertaken in Chile from 1990 to date. It analyses its context, from a historical perspective, and attempts to identify the factors that have both determined national data improvement and facilitated their use. The Chilean example provides evidence that tradition, receptiveness to foreign ideas, and benchmarking with international data shaped the use of data, assisted by the political influence of physicians and, later, other technocrats. Except for during the Pinochet dictatorship, the long-term political driver in decision-making has been the pursuit of equality.This article covers six main topics. The first four sections focus on the drivers and uses of national data and national estimates. The second part, with two sections, discusses first the use of domestic and global estimates, and secondly, how to build capacities for data collection, analysis, and interpretation for policy-making.This article uses a qualitative methodological approach to undertake a case study of the Chilean experience with data on decision-making. As primary sources of information, we use our first-hand experience as officials of the Ministry of Health (MOH) and the Ministry of Finance during the 2005 health reform policy formulation and later discussion in Congress, and before since 1990.Secondly, the methodological strategy included a literature review, considering official sources from the MOH, the World Bank, and the Chilean National Library of Congress, as well as several books, historical accounts, and policy reports documenting health policy-making in Chile during the twentieth century. The review was complemented by a systematic MEDLINE search using the terms ‘Health Care Reform [MESH] and Chile [MESH]’ and ‘Chile [MESH] and AUGE [all fields]’ . From the resulting items, only those describing health reforms were finally considered, looking specifically for the use of data.Chile is a South American country with a population of nearly 18 million people, 81 years of life expectancy at birth, and high per-capita income, but where inequality remains one of the greatest challenges . Health Although total health expenditure has increased, Chile has one of the lowest figures for total health spending among Organisation for Economic Co-operation and Development (OECD) countries. It has a low proportion of public expenditure on health  and is second only to the USA regarding the share of private financing, mainly the result of out-of-pocket payment by individuals. According to the OECD, health financing in Chile ‘remains inefficient and inequitable’ ,7.Chile has a long tradition of collecting and publishing national statistics. In 1843, the statistical service was established, and in the same year the population censuses law was enacted ,10.It has been suggested that European liberal ideas greatly influenced the development of a medical culture with a deep interest in social problems, which furthered social policies in health. Indeed, liberal trade and openness during the war of independence allowed the unrestricted arrival of many European physicians, especially from the UK and France. They had significant professional and social prestige, and influenced the creation of the medical school, with a positivist approach based on evidence and scientific rigour. Some of them also developed successful political careers ,12. In tAn early example of health policies based on a scientific approach is the enactment of the Mother–Son Law in 1936, which aimed to reduce infant mortality and prevent the causes of disease and premature disability. The Minister of Health, Cruz-Coke, was a prominent physician, a scholar, and a leading researcher. At the beginning of his administration, he commissioned several studies to support effective evidence-based policies. He also enacted the Preventive Medicine Law in 1938, which enforced periodic screening tests to detect and provide prompt treatment to priority health problems, such as tuberculosis (TB) and syphilis. His surveys and data analysis provided evidence of the burden of avoidable morbidity and mortality among the working class, due to the lack of access to health care. Cruz-Coke was elected to the Senate (the upper house of parliament) for the Conservative Party after his period in the Ministry. He unsuccessfully ran for president in 1946, remaining in the Senate for several years –17.The single most significant development was Salvador Allende´s book ‘La Realidad Médico-Social Chilena’ , which offers an outstanding example of the use of national data, along with global comparative analysis, to underpin a health policy proposal. The book was a real manifesto of social epidemiology, and is considered the starting point of the Social Medicine movement in Latin America ,19.Allende, Minister of Health at the time, describes the situation of a country in which 73% of the population lived in poverty. The infant mortality rate was 250 per 1000 live births, almost the highest recorded in the world at that time, and only half of the children born each year would live beyond the age of 10 years. This was very different from what we see today, where the infant mortality rate is slightly over seven per 1000 live births. Chilean society showed marked structural inequalities, which were exacerbated by the 1939 Chilean earthquake .According to Waitzkin, in his book Allende conceptualized illness as a disturbance of the individual fostered by social deprivation, a vision deeply influenced by Virchow´s views about the social determinants of health . AllendeThe consequences of the earthquake contributed to the sense of urgency around the need to unify and reform the health and social security systems created in previous decades. Then, in 1941, Allende sent a bill to Congress to implement a health system based on socialized medicine. Ten years later, the law was enacted, with significant changes, creating the National Health Service (NHS), the first in the Americas to guarantee universal health care  ,23.The NHS, which operated through a countrywide network of services, had a profound impact on health indicators, with a sharp decline in TB mortality and a progressive improvement of maternal and child indicators . HoweverThe restoration of democracy in 1990, with the promotion of social justice with macroeconomic balance and growth as centrepieces of the Chilean government’s development agenda, brought new impetus to the development of social statistics and inequality analysis to underpin policy-making in health .During the dictatorship, health expenditure was sharply reduced, with no investment in hospital infrastructure for 17 years. Primary-care level expansion was maintained, however, devoted mainly to maternal and child health problems. A comprehensive national health information system existed, collecting demographic, epidemiological, and health resource utilization data. Nevertheless, there was little practical use of this data for health situation analysis or health needs assessments, while financial analysis was the primary planning activity. Conversely, owing to the political emphasis on efficiency and targeting to alleviate extreme poverty, new instruments were developed, such as the Socio-Economic Characterization Survey (known by its acronym CASEN) to measure poverty and allocate social aid, including health care ,24.By 1990, the health system was in a deep crisis caused not only by a lack of resources, but also by inefficiency in service delivery, related to distortions of health financing mechanisms. The lack of complementarity among different levels of care was a critical problem, as was the inadequate response to changing health needs associated with the demographic transition. Government policies favoured primary health care and the private sector, neglecting the modernization and maintenance of public hospitals. Cardiovascular diseases had been the leading cause of death since 1970, but the priority in spending and health-care resources went to maternal and child health and communicable diseases; an enormous unmet demand for specialist care and tertiary hospitalizations existed ,27.This was the context within which in 1990 the Chilean government initiated a health reform, with financial and technical assistance from the World Bank, aiming to improve the effectiveness, efficiency, and quality of health services, particularly for poor people. Economists specializing in social policies provided the technical leadership for the reform, which involved numerous young professionals: economists, engineers, lawyers, and physicians. Many of them later took up important positions in the government and international organizations; a generation of technocrats.The preparatory phase consisted of several studies, covering all components and entities of the health system. The findings of these studies led to the reorganization of the MOH and transformation of payment methods, from fee for service to prospective per-capita and diagnosis-related payment in primary health care and hospitals, respectively. In parallel, investments in health facilities for a new health-care model were implemented, including new ambulatory facilities, designed to deliver secondary and tertiary services ,28.However, the reform maintained the structural design inherited from the Pinochet dictatorship. As a result of the introduction of market justice in social health insurance during the 1980s, the health system became highly segmented, a strong determinant of inequality in access to health care. The incoming government had other significant challenges in the early 1990s, to restore democracy and demonstrate good governance. There simply was no political ground for structural changes in the health sector, and there has not been so far.In 1994, the World Bank published its report ‘Chile: the adult health policy challenge’, which analysed the implications of demographic and epidemiological trends for health-care expenditure and intervention programmes. The first ever estimates of the Chilean burden of diseases and injuries, measured in disability-adjusted life-years (DALYs), were produced, based on simulations of national mortality data. These provided the basis for the definition of health priorities and health technology assessment .In the previous year, the World Bank had published its controversial ‘World Development Report 1993: Investing in health’, which proposed packages of public health measures and essential clinical care priorities for health spending, based on the estimation of the burden of disease and the cost-effectiveness of interventions. Influenced by these ideas, the Minister of Health – an economist – decided to carry out a national estimation of DALYs based on national empirical data rather than the earlier statistical models used by the World Bank. This was the third such study in Latin America, after Mexico and Colombia. Chilean professionals from the MOH executed the study, with direct technical assistance from Harvard University. A study of social preferences in health, using qualitative research methods, was conducted in parallel by the MOH. Both studies were designed to support decision-making for prioritizing investments in health ,31.Since their introduction, there have been many criticisms of the use of DALYs, partly because of their complexity, but also owing to ethical problems and controversies around the use of parameters such as the differential societal value of individuals at different ages, the disability weights, and the discount rate . This coHowever, DALYs were instrumental in emphasizing the importance of leading causes of disability, such as depression, substance abuse, and musculoskeletal disorders. Chileans were conscious of the relevance of these health needs in a rapidly ageing population, as shown in health perception studies, and this helped to validate the use of the indicator.The results of the burden of diseases study had a profound impact on reorienting health policies . The stuHealth inequality between population groups and inequality in access to health care were the focus of attention during this period. In 1998, the MOH, together with the Pan American Health Organization, convened an international seminar on ‘Equity and efficiency in decision-making in health’, fostering broader discussion on these issues. The main topics were the impact of the social determinants of health, geographical inequality in the burden of diseases, and the mismatch of the health system to the priority needs. The burden of disease demonstrates the preponderance of non-communicable diseases, and despite increased investment during the 1990s, the public health system still lacked the resources to address the new health priorities. Therefore, the private–public gap remained a significant equality concern ,36.The discussion also covered MOH strategies to address inequality in access, including the new public insurance (FONASA) prioritizing the benefits mechanism, such as the ‘program of complex services’, based primarily on cost and waiting lists, instead of epidemiological criteria.In 2000, a new cycle of health reforms began in an attempt to reduce inequalities. The Chilean government implemented an innovative second-generation health reform, the central focus of which was the recognition of the right to health. A physician headed the Inter-ministerial Committee leading the process, which involved the Ministries of Health and Finance, and the General Secretariat of the Presidency . On thisThe first step was the definition of health objectives for the decade 2000–2010, called ‘Objetivos Sanitarios para la Década 2000–2010’ (OS2000-10) . OS2000-The primary instrument for achieving health goals was the creation of a regime of explicit health guarantees (known by the acronym AUGE) for prioritized health problems  . The lawA legal decree, signed by both the Minister of Health and the Minister of Finance, defines for each of the 80 problems the requisites of eligibility, the maximum waiting times, the list of health interventions covered, and the co-payment limit. It is the responsibility of the medical insurance provider, either public or private, to comply with these guarantees. This establishes the minimum effective health coverage for every individual, regardless of their level of contribution. This feature is considered one of the main achievements of the reform ,27,39.Before the reform, the Chilean Constitution only stated second-generation rights regarding health care. The jurisprudence considers these as a mere statement of intention, and therefore the state and the courts are not obliged to enforce them, except for the right to choose the health system, either public or private. Since the reforms, AUGE has constituted the core of the constitutional right to health, which may be enforceable in compliance with both the AUGE law and the constitutional mandate –42.AUGE was progressively implemented, beginning with 25 health problems in 2005 and reaching 80 in 2013. Priority setting used three criteria: (1) priority diseases, as defined in the health objectives of the decade; (2) the existing interventions already covered by the public insurance through the ‘program of complex services’; and (3) social preferences, including the use of the ‘rule of rescue’, the imperative that people feel to help identifiable individuals facing avoidable death ,44. The The AUGE law sets a schedule of mandatory technical, epidemiological, and economic studies that support decision-making for updating the priority list every 3 years through a legal decree . The preNew epidemiological and statistical tools were developed to monitor the outcome and impact of the reform, which strengthened the public health surveillance system. To begin, the MOH implemented the AUGE information system, which oversees the compliance with the four legal guarantees. In addition, a national health survey, with biomarkers, was implemented, along with two other surveys on quality of life and patient satisfaction and health spending. Lastly, health questions of the CASEN household survey were adapted to measure access to and utilization of health services. Thereby, it is now possible to disaggregate access according to age, gender, ethnic origin, socio-economic status, health insurance, residence, and migrant status. It also has questions about AUGE use and perception.Even before its enactment, the AUGE law was the target of severe criticism. One of the earliest and more relevant reproaches was the risk of neglect of non-priority health problems. The waiting lists for these have worsened, despite interventions to reduce them ,47.The entitlement to timely access obliges health insurers that exceed the maximum waiting time to purchase health interventions outside their network. In practice, FONASA (the public insurer) has been unable to fully comply, owing to shortages of specialists, hospital beds, and technology in public facilities. Thus, the public sector has been increasingly purchasing services from private providers, leading to rising costs and reinforcing the underfunding of public health providers.Clearly, AUGE has been unable to overcome the problems generated by a fragmented system, segmented by income and health status. During the parliamentary discussion of the bill, right-wing parties rejected the setting up of a compensation fund to finance AUGE, designed to pool risks and create solidarity between the public and private sectors .On the other hand, in the 10 years since its implementation, the reform has shown benefits regarding access and health impact. Chilean´s utilization of health-care services has increased, although gaps between the richest and the poorer people remain . For exaIn Chile, national data are used for decision-making and health policy design, while data and global estimates are used for comparative purposes. They serve to benchmark progress and identify areas with potential for improvement. In the absence of national data, it is customary to use global estimates, such as in the case of rare diseases, or for health intervention efficacy analysis, which is usually performed based on international data.The World Health Organization (WHO) traditionally considers Chile among the countries with reliable statistics ,53. DiscIn 2010, Chile joined the OECD. This has involved a challenge for the national statistical systems, which have had to adapt to the measurements and standards of this organization. In practice, the accession to the OECD has meant changing the tradition of benchmarking progress against other Latin American countries. Thus, Chile, which had long been used to its position as the best performing country for health in the region, suddenly found itself classified among the worst performers among members of the OECD ,7,54.This new performance benchmarking has fuelled debate in the academic and political environment, and shows the potential impact of comparative cross-country benchmarking based on sound empirical data.Among the main challenges for the future is the need to strengthen the health information infrastructure to improve the opportunity of data, to incorporate quality of care indicators, and to provide disaggregation to monitor equality in health coverage. The different surveys allow us to disaggregate data by gender, socio-economic and minority group status, but this is not the case for administrative registries. In a study on universal health coverage (UHC) in Chile, we described the shortcomings of the MOH registries, which impede to assess equality in health coverage for many public health programmes, such as vaccination, TB, HIV/AIDS, antenatal care, and birth control .It is also relevant to update studies on the national and subnational burden of diseases, cost-effectiveness, and social preferences, to bring AUGE coverage up to date. There is an ample window of opportunity to improve health system performance through the use of both national data and international benchmarking.The struggle to adapt health services to changing health needs is one of the primary challenges for many low- and middle-income countries. During the past decade, Chile has opted for a data-driven priority setting and rights-based approach in health reforms, providing entitled access to health care for priority diseases. In support of this process, the MOH strengthened its information systems and created new tools to monitor results, clearing a path for other countries to follow. However, it did not change the structural conditions of the segmented health system, which is a common situation in many Latin American countries. The Chilean example has shown some gains in health status, but a persistent inequality in access to health care. It is also an example of what Schuftan has described as ‘being sucked into dreaming that technical solutions in public health would right the wrongs’ . NeverthSome factors associated with using data in decision-making persistently appear throughout history. Among them are the openness to foreign influences, first derived from the arrival of European doctors with liberal ideals, and then the international comparative analysis as an element of judgement about the national situation. It is also important to acknowledge the importance of policy and prioritization frameworks developed by international agencies.In Chile, doctors have been influential political players in making health policy decisions, taking a positivist, data-based approach, which is currently adopted by economists. The definition of inter-ministerial working teams, addressing health problems from health, economic, and political perspectives, has helped to maintain a tradition of making decisions based on the use of data in the health sector. As the backbone of policy development, there is an ongoing need to confront structural inequalities, a feature of Chilean society that we have failed to remedy ,57.The use of studies and national data starting during the 1990s and in the reform of 2005 give an impression of continuity in the line of thought, but in practice, the systematic adoption of evidence-informed policy and prioritization proceeded patchily .10.3402/There was no planned connection between the 1990s’ studies and the health reform that began in 2000 and resulted in the AUGE law. The authorities belonged to the same political coalition, but with different perspectives about the health sector.We maintain that the studies performed during the 1990s, on the burden of diseases and cost-effectiveness of health interventions, were used because some technical teams that worked on them stayed at MOH during both periods. As already mentioned, the studies were not intended to implement a system of enforceable rights for priority diseases; they were carried out to support investment decisions on health-care infrastructure and medical equipment. However, the health authorities responsible for the 2005 reform saw that those studies could give them a technical substrate for prioritization.Having human resources capable of generating and analysing information is certainly a necessary condition for the use of data in decision-making, but it is not a sufficient one. The authorities can make decisions with or without data, so the technical experts and statistical analysts have the responsibility to provide the best information available in a timely and understandable manner. There is a liaison between technical knowledge and the political authorities, which requires physical closeness between the two worlds. For example, the institutionalization of analytical capacity at the MOH, first in the department of epidemiology and later with the creation of the department of statistics and health economics, gave rise to the division of health planning. This division is responsible for formulating the national health strategy and the development of the necessary studies for AUGE.It is also important to have budgets to support operational research aimed at solving specific problems of the health system, which enables the creation of links between the worlds of academia and public health management.The Chilean experience shows that the availability of technical expertise in the MOH facilitated the use of national data in decision-making processes of the reforms from the 1990s onwards. However, the maintenance of such capacities can never be taken for granted and requires constant vigilance. Job instability and career shortcomings discourage the retention of professionals in the public service, and also threaten the political independence of the health information system.Currently, the directors of both the National Statistical Institute and the Civil Registry and Identification Service are recruited through an open and competitive process, carried out by consultants and conducted by the public Senior Executive Service System (SESS). In contrast, directors of the health statistics and epidemiology departments at MOH are appointed by the authority, and only a minority of civil servants at MOH have tenure. During recent shifts of government, all of the directors mentioned above were replaced, despite their connection with SESS. The turnover of staff members coincided with serious problems in the quality of data, such as the failure of the last population census (2012), polemics about poverty measurements, and health population surveys being suspended or delayed ,59.Despite these problems, the country has maintained the discipline of decennial health plans; the current one is the national health strategy 2011–2020 . Also, rFinally, global estimates and global commitments such as UHC and sustainable development goals play a major role in mobilizing the political will of the leaders to invest in their information systems and generate evidence for decision-making. Transparency in the handling of data by agencies such as the WHO and accountability of international commitments are strong incentives for resource mobilization for capacity building in the capture, analysis, and use of data.Chile’s experience with international estimates, particularly in the 1990s, shows how these can have an influence within a country, even though national estimates take precedence in local decision-making. The global progress in methods to provide comprehensive estimates of the burden of disease has led to advances in analyses in Chile, with international technical support, and influences the national analytical work, including estimates. In addition, internationally comparable statistics are a valuable input into the policy debate.


Professor Mirko Tos, the best otorhinolaryngologist in the World, passed away on January 16, 2018, in Denmark at the age of 87. His books are the leading textbooks used to teach otologic surgery. He published nearly 700 articles and was the most productive otolaryngologist at the peak of his career  Days-New Advances in Otology Symposium, the 5th Balkan Congress of ORL&HNS, and the Trakya Society of ORL&HNS Meeting on Secretory Otitis Media, respectively. He was always happy for being in Edirne and never refused us (Prof. Mirko Tos, besides having many invitations from several countries, also visited Trakya University and Edirne several times and gave important lectures here. His first visit was in 2001, again in 2006, and his final trip was in 2010. He was the guest of honor and the invited speaker at all three meetings: the 2fused us .Prof. Tos was originally from Slovenia and moved to Denmark in 1957 . He becaBalkan Medical Journal (In addition to his well-known textbooks, he has several surgical techniques for the treatment of ear diseases, classifications, and theories for otologic pathologies. His classification of cartilage tympanoplasties was first published in 2007 in his article published in the Trakya University Medical Faculty Journal, currently entitled, the  Journal . Additio Journal .One of the memorable mottos of Prof. Tos is that “speak depending on your own data!” . He ofteDenmark was the best country in the world regarding the number of articles published in SCIE per number of inhabitants during the end of the 90s . This stProf. Tos has also been the Honorary Member of the Balkan Society of ORL&HNS and the Trakya Society of ORL&HNS. We have shared many memories, which are not forgettable . He has


However, it is important to observe the proportion of vegetables and cereals in the diet, which may change according to the culture of each place and country, causing higher or lower risk.Plants have the potential to absorb and accumulate larger amounts of several heavy metals. In studying heavy metal contents in vegetables fertilized with wastewater in India, Singh et al.  found thThe use of waste as a source of nutrients in plant production systems, traditional, and organic, is common worldwide, and important strategy for nutrient cycling. However, long-term application of such waste causes the increase of HM concentrations in soils, increasing HM uptake by plants and assimilation in edible organs such as grains, as indicated by the data presented in Table RdRC: wrote the first draft of the manuscript. MS: organized the database. JC, LG, CC: senior researchers in the field of soil science. They made specific contributions of the area. FR: senior researchers in the field of plant physiology. They made specific contributions of the area. ML: senior researchers in the field of agroecology. They made specific contributions of the area. All authors contributed to the revision of the manuscript, read and approved the version sent.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.