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Background This project aimed to identify practices, knowledge and confidence in diagnosing and treating influenza in health systems serving American Indian/Alaskan Native communities and to provide education to support alignment with IDSA guidelines. Methods Anonymous baseline surveys were completed electronically by healthcare professionals (HCPs) from Cherokee Nation Health Services (CNHS) and the Northwest Portland Area Indian Health Board’s teleECHO program. Responses informed a 2-part series of live virtual educational trainings featuring pre- and post-program surveys and team-based action planning. Results Baseline surveys were completed by 247 HCPs. 149 attended the 1st meeting, and 90 attended the 2nd. For outpatient influenza diagnosis, 72% of baseline survey respondents reported primarily using rapid antigen testing, and 11% reported using molecular testing. Similarly, 15% of learners in the live meetings correctly identified rapid molecular assay as the guideline-recommended test, which improved to 72% afterwards. All 9 CNHS outpatient health centers switched from rapid antigen to molecular testing for influenza diagnosis after the training. Influenza treatment decision-making was assessed using a case vignette. For a patient at high risk for complications with flu-like symptoms but stable for outpatient care, 23% of learners in the live meetings correctly chose to start antiviral treatment immediately, which improved to 54% after the program, and more learners felt confident applying diagnostic test results to treatment, from 31% before to 68% after the training. Learner confidence also improved from 19% feeling confident in selecting antiviral treatment and 33% feeling confident in identifying high risk patients before the program to 60% and 70% afterwards, respectively. Action plans prioritized by the HCPs included: patient engagement (61%), reviewing guidelines and data (57%), improving patient adherence to treatment (50%), and developing criteria for immediate antiviral treatment (50%). Conclusion Knowledge and confidence in influenza management improved after the training, as did system-wide alignment with IDSA-recommended diagnostic testing. Studies evaluating the clinical impact of this activity is warranted. Disclosures Jorge Mera, MD, FACP, Abbvie: Grant/Research Support|Gilead Sciences: Grant/Research Support|Gilead Sciences: Received one time honorarium for participating as a panelist in a COVID-19 Webinar|Merck: Grant/Research Support.

In March 2020, a tribal telehealth program—the Indian Country Extension for Community Health Outcomes (ECHO)—added emergency COVID-19 to its programming to support the pandemic response. A long-standing relationship with a network of Indian Health Service, tribal, and urban Indian clinicians supported a rapid launch of the COVID-19 telehealth program. This nationwide service offered primary care clinicians and staff serving American Indian/Alaska Native people access to virtual learning opportunities, expert clinical recommendations, technical assistance, and capacity building. From March 12, 2020, through April 30, 2021, the program provided 85 clinical sessions in 12 months, with an average participation of 120 attendees per clinic (N = 11 710). Attendees could complete a voluntary evaluation form for each session via an online link. A total of 2595 forms were completed. Attendees came from 33 states and 206 unique locations, primarily from the Pacific Northwest (n = 931, 35.9%). Most pharmacists (78.1%), providers (ie, medical doctor, doctor of osteopathy, advanced practice nurse, physician assistant, or clinical nurse midwife; 70.8%), and nurses (59.6%) gave the sessions the highest rating of “very satisfied.” The highest proportion of attendees indicating that they planned a change in practice were pharmacists (68.0%), nurses, (64.1%), and providers (61.3%). Most attendees (93.1%) said that the COVID-19 sessions gave them a sense of social support. Lessons learned were that (1) a telehealth platform can be quickly retasked for emergency response with no further delays, (2) a telehealth network can be scaled up quickly with participation from preexisting relationships, and (3) the platform is flexible and adaptable to the needs of participants. An existing telehealth program can be a key part of timely, relevant, large-scale emergency readiness and response efforts.

American Indian/Alaska Native communities are at higher risk of poor outcomes from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). The Northwest Portland Area Indian Health Board’s program Indian Country Extensions for Community Healthcare Outcomes (ECHO) initiated telehealth sessions for health professionals. All resources were centralized at www.IndianCountryECHO.org. In its first six weeks, the program had 4,579 attendees. Participants submitted 563 questions to specialists. There were 22,683 webpage views, more than three times the pre-COVID-19 baseline. Evaluation found 94 percent of clinicians reported knowledge increase and 93 percent reported greater social support, demonstrating that a teleECHO network serving Indian country is an important part of emergency response.

Background: Injection drug use is an important public health issue in the United States, and estimates indicate that American Indian and Alaska Native people are disproportionately affected. Injection drug use is also the leading cause of Hepatitis C virus (HCV) infection in the United States, attributable to over half of all cases, and contributes to 44% of human immunodeficiency virus (HIV) acquisition in American Indian and Alaska Native females. Existing estimates of American Indian and Alaska Native people who inject drugs are limited. We aimed to estimate the number of people who inject drugs in Cherokee Nation.Methods: A two-sample, capture-recapture approach was used. The first data source was an abstraction of Cherokee Nation Health Services electronic medical records from February 2017 through December 2018. The second data source was an abstraction from Cherokee Nation’s HCV Elimination Program Database from August 2015 through December 2018. Individuals were included in the abstractions if they were asked if they had injected drugs in the past six months during their health visit. The indirect prevalence estimate of people who inject drugs was calculated in accordance with the UNAIDS/WHO Guidelines on Estimating the Size of Populations Most at Risk to HIV.Results: In total, 198 individuals across both data sources reported that they had injected drugs within the past six months. This included 123 unique individuals from the first source, 69 individuals from the second source, and six individuals who were included in both sources. Capture-recapture calculations indicated an estimate of 1,613 people who inject drugs (95% CI: 404, 2,821). Conclusions: This study was the first attempt at estimating the number of people who inject drugs in Cherokee Nation, and one of the few existing studies to estimate the number of American Indian/Alaska Native people who inject drugs in the United States. Gaining knowledge about the prevalence of people who inject drugs in Cherokee Nation will inform strategies to support addiction care and treatment among people who inject drugs living in Indian Country.

The 69th World Health Assembly endorsed the Global Health Sector Strategy for Viral Hepatitis, embracing a goal to eliminate hepatitis infection as a public health threat by 2030. This was followed by the World Health Organization's (WHO) global targets for the care and management of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. These announcements and targets were important in raising awareness and calling for action; however, tracking countries’ progress towards these elimination goals has provided insights to the limitations of these targets. The existing targets compare a country's progress relative to its 2015 values, penalizing countries who started their programmes prior to 2015, countries with a young population, or countries with a low prevalence. We recommend that (1) WHO simplify the hepatitis elimination targets, (2) change to absolute targets and (3) allow countries to achieve these disease targets with their own service coverage initiatives that will have the maximum impact. The recommended targets are as follows: reduce HCV new chronic cases to ≤5 per 100000, reduce HBV prevalence among 1-year-olds to ≤0.1%, reduce HBV and HCV mortality to ≤5 per 100000, and demonstrate HBV and HCV year-to-year decrease in new HCV- and HBV-related HCC cases. The objective of our recommendations is not to lower expectations or diminish the hepatitis elimination standards, but to provide clearer targets that recognize the past and current elimination efforts by countries, help measure progress towards true elimination, and motivate other countries to follow suit.

This cohort study evaluates the first 22 months of implementation of the Cherokee Nation Heath Services community-based program designed to eliminate hepatitis C virus (HCV) infection., Key Points Question Can a community-based tribal hepatitis C virus (HCV) elimination program be implemented successfully in a rural setting? Findings In this cohort study, first-time HCV screening coverage increased from 20.9% to 38.2% from 3 years before to 22 months into implementation of the Cherokee Nation Health Services HCV elimination program. Identification, treatment, and cure of newly identified current HCV infections increased. Meaning In this study, implementation of a community-based HCV elimination program was associated with an improved cascade of care; this information may serve other organizations planning to implement similar programs in large rural areas., Importance In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals. Objective To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure. Design, Setting, and Participants This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre–elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018. Exposure The CN HCV elimination program. Main Outcomes and Measures The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre–elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses. Results Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre–elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources. Conclusions and Relevance This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.

Background: Injection drug use is an important public health issue in the United States, and estimates indicate that American Indian and Alaska Native people are disproportionately affected. Injection drug use is also the leading cause of Hepatitis C virus (HCV) infection in the United States, attributable to over half of all cases, and contributes to 44% of human immunodeficiency virus (HIV) acquisition in American Indian and Alaska Native females. Existing estimates of American Indian and Alaska Native people who inject drugs are limited. We aimed to estimate the number of people who inject drugs in Cherokee Nation.Methods: A two-sample, capture-recapture approach was used. The first data source was an abstraction of Cherokee Nation Health Services electronic medical records from February 2017 through December 2018. The second data source was an abstraction from Cherokee Nation’s HCV Elimination Program Database from August 2015 through December 2018. Individuals were included in the abstractions if they were asked if they had injected drugs in the past six months during their health visit. The indirect prevalence estimate of people who inject drugs was calculated in accordance with the UNAIDS/WHO Guidelines on Estimating the Size of Populations Most at Risk to HIV.Results: In total, 198 individuals across both data sources reported that they had injected drugs within the past six months. This included 123 unique individuals from the first source, 69 individuals from the second source, and six individuals who were included in both sources. Capture-recapture calculations indicated an estimate of 1,613 people who inject drugs (95% CI: 1,530.27, 1,694.7). Conclusions: This study was the first attempt at estimating the number of people who inject drugs in Cherokee Nation, and one of the few existing studies to estimate the number of American Indian/Alaska Native people who inject drugs in the United States. Gaining knowledge about the prevalence of people who inject drugs in Cherokee Nation will inform strategies to support addiction care and treatment among people who inject drugs living in Indian Country.

American Indian/Alaska Native (AI/AN) and Canadian Indigenous people are disproportionally affected by hepatitis C virus (HCV) infection yet are frequently underrepresented in epidemiologic studies and surveys often used to inform public health efforts. We performed a systematic review of published and unpublished literature and summarized our findings on HCV prevalence in these Indigenous populations. We found a disparity of epidemiologic literature of HCV prevalence among AI/AN in the United States and Indigenous people in Canada. The limited data available, which date from 1995, demonstrate a wide range of HCV prevalence in AI/AN (1.49%–67.60%) and Indigenous populations (2.28%–90.24%). The highest HCV prevalence in both countries was reported in studies that either included or specifically targeted people who inject drugs. Lower prevalence was reported in studies of general Indigenous populations, although in Canada, the lowest prevalence was up to 3-fold higher in Aboriginal people compared with general population estimates. The disparity of available data on HCV prevalence and need for consistent and enhanced HCV surveillance and reporting among Indigenous people are highlighted. HCV affects Indigenous peoples to a greater degree than the general population; thus we recommend tribal and community leaders be engaged in enhanced surveillance efforts and that funds benefitting all Indigenous persons be expanded to help prevent and cover health care expenses to help stop this epidemic.

Hepatitis C virus (HCV) disproportionately affects American Indians/Alaska Natives (AI/AN). The Indian Health Service (IHS), via federal and tribal health facilities provides medical services to an estimated 2.2 million AI/AN people in the United States. HCV diagnoses, defined by International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM) codes, were analyzed from 2005 to 2015. Results showed 29,803 patients with an HCV diagnosis; 53.4% were among persons born 1945-1965 and overall HCV burden was higher among males than females. These data will help inform local, regional, and national efforts to address, plan for and carry out a national strategy to provide treatment for HCV infected patients and programs to prevent new HCV infections.

Introduction The Cherokee Nation Comprehensive Cancer Control Program collaborated with the Cherokee Nation Hepatitis C Virus (HCV) Elimination Program within Cherokee Nation’s Health Services to plan and implement activities to increase knowledge and awareness of liver cancer prevention among health care providers and the Cherokee Nation community. From August 2017 to April 2018, the 2 programs implemented liver cancer prevention interventions that focused on education of health care providers and community members. We used descriptive statistics to analyze data collected from a brief, retrospective pre–post survey for each intervention. We assessed overall awareness and knowledge of liver cancer and ability and intention to address it on a scale of 1 to 5. Project Extension for Community Healthcare Outcomes didactic sessions resulted in a 1.1-point improvement, provider education workshops resulted in a 1.4-point improvement, and presentations at community coalition meetings resulted in a 1.7-point improvement. Our study shows that HCV interventions can be used by public health and medical professionals interested in controlling HCV and related diseases such as liver cancer.

INTRODUCTION American Indian/Alaska Native (AI/AN) populations are disproportionately affected by chronic hepatitis C virus (HCV) infection. Federal facilities of the Indian Health Service, in conjunction with Tribally operated and Urban Indian (I/T/U) health care facilities, serve an estimated 2.2 million AI/AN patients. The facilities are mainly rural and have few specialists. To fill the gap in specialists in I/T/U clinics, the Extension for Community Healthcare Outcomes (ECHO) telehealth model was used to support clinicians to treat HCV in primary care. METHODS Participants in 3 regional HCV ECHO networks serving AI/AN patients were surveyed by e-mail and text message to determine patterns of ECHO usage, usefulness, and barriers to treating patients with HCV at their primary care clinics. RESULTS From a total of 44 respondents from 72 eligible health care facilities, a majority (61%) stated that they started treating patients with HCV subsequent to participating in the telehealth program. Participants with more telehealth experience sought increasing complexity in patient case presentations. In California, 7 of 8 clinicians who had attended more than 10 ECHO sessions expressed diminishing need for ECHO sessions to manage cases (

Background Treatment for chronic hepatitis C virus (HCV) has rapidly evolved to simple, well-tolerated, all-oral regimens of direct-acting antivirals (DAAs). There are few data on the epidemiology of HCV in American Indians/Alaska Natives (AI/ANs), a population disproportionately affected by HCV. Methods In this retrospective cohort study, all HCV-infected AI/AN patients treated with DAA therapies between January 1, 2014, and February 24, 2016, in specialty clinics or by primary care clinicians participating in Extension for Community Healthcare Outcomes (ECHO) were included. Demographic, clinical, and virologic data on all patients treated for HCV from pretreatment through sustained virologic response at 12 weeks (SVR12) were collected. Results Two hundred eighty patients were included; 71.1% of patients (n = 199) were infected with genotype 1 (GT1), 18.2% (n = 51) with GT2, and 10.7% with (n = 30) GT3. At baseline, 26.1% (n = 73) patients had cirrhosis and 22.6% (n = 56) had active substance use disorder; eighty-eight percent (n = 232) of patients achieved SVR12. Among the 165 GT1 patients treated with sofosbuvir (SOF)/ledipasvir for 8, 12, and 24 weeks, SVR12 was achieved by 91.5% (n = 54), 92.2% (n = 71), and 100% (n = 13), respectively. Among GT2 patients, 87.2% (n = 34) and 71.4% (n = 5) treated with 12 and 16 weeks of SOF/ribavirin (RBV) achieved SVR12, respectively. Among GT3 patients, 100% (n = 2) and 83.3% (n = 20) treated with 12 and 24 weeks of SOF/RBV achieved SVR12, respectively. SVR12 rates remained high among patients with active substance use disorder. Conclusions DAA therapies are highly efficacious in HCV-infected AI/ANs. SVR12 rates remained high among patients with active substance use disorder. More steps must be taken to increase access to treatment for this underserved, vulnerable population.

Historically, chronic hepatitis C virus (HCV) treatment was response-guided. Clinical trials with sofosbuvir indicated on-treatment virologic response was not predictive of sustained virologic response (SVR) and hence response-guided therapy (RGT) was abandoned. The purpose of this study is to examine the association between on-treatment 4-week HCV RNA and SVR in patients treated in real-world practice. The study is a retrospective analysis of consecutive patients started on treatment with a sofosbuvir-containing regimen, January 1, 2014 through August 20, 2014, for HCV genotype 1–6 infection. Patients were treated by HCV specialists at 6 centers in the Project ECHO (Extension for Community Healthcare Outcomes) HCV Collaborative or in the community by primary care clinicians mentored by HCV specialists through Project ECHO. Patients were included if they were over 18 years, had evidence of chronic HCV, and were started on a sofosbuvir-containing regimen. The aspartate aminotransferase:platelet ratio index (APRI) was used to estimate fibrosis. The main outcome measures were 4-week HCV RNA and SVR. Overall SVR was 82.5 %. At week 4, HCV RNA was detected in 27.4 % of patients. Stepwise multivariable logistic-regression analyses identified APRI > 1.0, male sex, genotype 3, and detectable on treatment 4-week HCV RNA as independent predictors of failure to achieve SVR. In a real-world setting, a significant proportion of sofosbuvir treated patients have detectable on-treatment 4-week HCV RNA. Detectable on-treatment 4-week HCV RNA is associated with virologic failure. More data are needed to formulate guidance for RGT with newly available HCV therapies.

Background A leading infectious cause of hospitalization among adults in the United States is community-acquired pneumonia (CAP). The etiology and incidence of CAP in American Indians/Alaskan Natives (AI/AN) has not been described. Methods We conducted a retrospective study by reviewing the medical records of all AI/AN patients 18 years or older admitted to W.W. Hastings Hospital in Tahlequah, Oklahoma with a diagnosis of a respiratory infection from January 1, 2016 to December 31, 2016. Only patients with a radiographically confirmed CAP were included and those with a recent hospitalization or immunosuppressed were excluded. Patient demographics, comorbidities and results of molecular tests, antigen detection, high quality sputum culture and blood culture were reviewed. Population-based incidence rates of CAP requiring hospitalization were calculated according to age. Results From January 2016 through December 2016, 763 patients were admitted with a diagnosis of a respiratory infection, of which 193 (25%) met the inclusion criteria. Of this group, 103 (53%) had at least one pathogen detected: one or more viruses were detected in 47 (24%), one or more bacteria were detected in 63 (33%). The most common pathogens were Streptococcus pneumoniae (12% of patients), rhinovirus/enterovirus (11% of patients), respiratory syncytial virus (5% of patients), legionella pneumophila (4% of patients), and human metapneumovirus (4% of patients). The annual incidence of CAP was 13.6 cases (95% confidence interval, 11.9, 15.7) per 10,000 adults, with the highest incidence among adults ages 65–79 (43 cases per 10,000 adults) and those 80 years of age or older (102 cases per 10,000 adults). Seventy-five percent of patients had an underlying medical condition, 47% had diabetes mellitus (DM), followed by chronic obstructive lung disease (38%) and chronic heart disease (32%). Conclusion In this AI/AN population, a respiratory pathogen was identified in 53% of the cases despite the use of cutting edge diagnostic tests in most patients. Bacteria were detected more often than viruses. Compared with recent publications of CAP affecting non-Hispanic whites, non-Hispanic blacks and Hispanics, the population described in this study was older and had higher prevalence of DM. Disclosures All authors: No reported disclosures.

An estimated 3.5 million persons in the United States are living with hepatitis C virus (HCV) infection, resulting in approximately 20,000 deaths each year, primarily from cirrhosis or hepatocellular carcinoma (1,2). American Indian/Alaska Native (AI/AN) populations have the highest incidence of acute HCV infection among all U.S. racial/ethnic groups and are at greater risk for HCV-related mortality compared with the general population (3). In 2013, new antiviral drugs became available that make possible 8-12 week treatment regimens with fewer adverse events and are able to achieve sustained virologic response (SVR) in >90% of treated patients (4), equivalent to a cure of HCV infection. Also of note, HCV testing recommendations were expanded in 2012 by CDC and in 2013 by the U.S. Preventive Services Task Force to include one-time testing of persons born during 1945-1965 (the "baby boomer" cohort) in addition to anyone at increased risk for HCV infection (5,6). Given the availability of new HCV drugs, expanded testing recommendations, and high incidence of HCV infection in AI/AN populations, in October 2012, Cherokee Nation Health Services (CNHS) implemented a tribal HCV testing policy.* As part of the policy, CNHS added a reminder in the electronic health record (EHR) for clinical decision support and provided HCV education to primary care clinicians. From October 2012 to July 2015, among 92,012 persons with at least one CNHS clinic encounter, the cumulative number who received HCV screening for the first time increased from 3,337 (3.6%) to 16,772 (18.2%). The largest percentage of HCV screening was among persons born during 1945-1965. Of 715 persons who tested positive for HCV antibodies, 488 (68.3%) were tested for HCV RNA; among those 488 persons, 388 (79.5%) were RNA positive and were thus confirmed to have chronic HCV infection. Treatment was initiated for 223 (57.5%) of the 388 with chronic infection; 201 (90.1%) completed treatment, of whom 180 (89.6%) achieved SVR. CNHS has successfully increased HCV testing and treatment and is now collaborating with CDC and other external partners to develop an HCV elimination program for the Cherokee Nation that might serve as a model for similar settings.

La Corte Suprema chilena cuenta desde 1995 con salas especializadas para conocer determinadas materias. Uno de los principales objetivos de la reforma que creó esas salas consistió en asegurar una aplicación más cierta y uniforme de la ley. El presente estudio, que se concentra en la jurisprudencia producida por la Sala penal, se propone analizar en qué medida ese objetivo se alcanzó durante el período 1995-2002. Para ello emplea el marco conceptual definido por importantes estudios norteamericanos sobre el grado de seguimiento de precedentes de la Corte Suprema, entendiendo que la uniformación de la jurisprudencia es función precisamente del nivel de seguimiento de precedentes. De acuerdo con esos estudios, el grado de seguimiento de los precedentes de la Corte Suprema puede analizarse a lo menos en dos niveles: primero, dentro de la propia Corte Suprema, donde una actituáprecedencial de los jueces es función principalmente de una baja saliencia de la materia resuelta, lo que depende a su vez de circunstancias históricas específicas (Spaeth y Segal); y, segundo, en dirección "vertical", es decir, a nivel de los tribunales inferiores, donde un comportamiento congruente de estos últimos con la jurisprudencia de la Corte Suprema es función de determinados medios institucionales, bajo el modelo de la relación "mandante-agente" (Songer, Segal y Cameron). El presente estudio examina precisamente el grado de seguimiento de precedentes alcanzado por la Sala penal de la Corte Suprema y por las cortes de apelaciones, en relación con cinco precedentes de la primera. Un extenso análisis de sentencias y la conducción de entrevistas a ministros de la Corte Suprema, cortes de apelaciones y abogados penalistas, dan cuenta de los ambivalentes -cuando no pobres- resultados alcanzados por aquella reforma en materia de uniformación de la jurisprudencia de la Sala penal, tanto al interior de esta Sala como a nivel de las cortes de apelacionesSince 1995, the Chilean Supreme Court counts with specialized chambers for knowing determinate matters. One of the main objectives in creating these specialized chambers consisted in assuring a more certain and uniform application of the law. This article focuses on the case-law produced by the Supreme Court's criminal chamber, trying to assess the extent to which the goal of a uniform application of the law was achieved during the years 1995-2002. In order to do so, the study utilizes the conceptual framework elaborated by relevant American research on the following of precedents, assuming that a more uniform application of the law is the natural result of that kind of court behavior. According to that research, the degree to which the precedents set by a Supreme Court are actually followed can be ascertained in two levels: first, by examining the phenomena within the Supreme Court itself, where a justice's precedential attitude depends on a low level of salience of the issue addressed, which in turns depends on specific historical circumstances (Spaeth & Segal); second, by studying the issue in a 'vertical' direction, that is, through the examination of the extend to which the behavior of lower court's is congruent with the jurisprudence elaborated by the Supreme Court, which depends on certain institutional conditions studied under the principal/agent relationship model (Songer, Segal & Cameron). This study examines precisely the degree of precedent-following exhibited by the Criminal Chamber of the Chilean Supreme Court and by the country's High courts with regard to five precedent-setting cases decided by the former. After an extensive analysis of court decisions and in depth-interviews of Supreme Court's justices and High Court's judges, as well as criminal-lawyers, the study concludes that the introduction of a Supreme Courts' Criminal Chamber has produced ambivalent, if not poor, outcomes in terms of a uniformity of its jurisprudence, both within the Criminal Chamber itself and at the High courts' level

Community-acquired pneumonia (CAP) is probably one of the infections affecting ambulatory patients for which the most diverse guidelines have been written worldwide. Most guidelines agree that antimicrobial therapy should be initially tailored according to either the severity of the infection or the presence of co-morbidity and epidemiology. Nevertheless, a great variability may be noted among different countries in the selection of first choice antimicrobial agents, even for cases considered as low-risk. This may be due to the many microbial causes of CAP and specialties involved, as well as different health-care systems which affect the availability or cost of antibiotics. However, many countries or regions adopt some of the guidelines or design their own recommendations, regardless of the local data, probably because of the scarcity of such data. A committee composed of South American infectious diseases specialists and microbiologists, with strong interest and recognized experience in CAP, were convened to establish a working group (ConsenSur) for designing a local evidence-based practice guideline for the initial management of CAP. This supplement is intended to give a practice recommendation for the initial antimicrobial treatment of CAP upon the basis of local evidence, in the hope of procuring a suitable tool for use by the different health-care providers concerned with the management of this infection in South America or in other countries where the main considerations for CAP are comparable.

Los 33 hospitales públicos del Gobierno de la Ciudad de Buenos Aires (GCBA) adquieren sus insumos en forma descentralizada. En septiembre de 1996, la Secretaría de Salud del GCBA implementó una política de monitoreo de precios de compra. En este trabajo utilizamos la base de datos generada por esta política para analizar dos cuestiones relacionadas. En primer lugar, estudiamos el efecto de la implementación de la política sobre los precios. Los resultados muestran que la política logró una reducción de precios, pero que el efecto transitorio fue mayor que el efecto permanente. En segundo lugar, analizamos el efecto de los salarios de eficiencia recibidos por los jefes de compras de cada hospital sobre los precios. Nuestra evidencia empírica no señala que mayores salarios de eficiencia induzcan menores precios de compra. También presentamos resultados de encuestas que muestran al ausentismo como la forma más grave de abuso de sus cargos por parte de médicos y enfermeros en los hospitales públicos.