Regarding the generational changeover

31 Jan
Joan Escarrabill

The day before turning 65 last November, I climbed up the 238 steps of the Pyramid of the Sun in Teotihuacan (near FD Mexico). I did it with only a short break halfway up. At the top I had dyspnoea but I was able to hold a conversation without difficulty. I went down backwards holding onto the guide rope because my left knee didn’t allow me to go down in a conventional way, face forward, but I did get down. Human beings have the tendency of setting temporary goals arbitrarily. Establishing 18 as the legal age has nothing to do with the maturity of a person and nor does being 65 make you old. To understand the idea of “getting old” it might be more objective to remember, for example, “the first time that  …”

  • … a resident doctor or student speaks to you in a formal way.
  • … an unknown person, on the street, identifies you with a “sir”.
  • … a young person offers you their seat on the underground or bus.
  • … you come across a book in a second-hand bookshop and see that you have the same one, bought many years ago (and remember perfectly well where and when you bought it).
  • … you realise you are no longer able to run.
  • … you forget to hail your bus or don’t run down the stairs in an underground station to catch a train.
  • … you look for the banister to descend a staircase.
  • … you receive a letter from the Town Council saying that you are eligible for a “pink pass” (senior citizen’s transport pass)
  • … in a professional meeting you are asked directly how long you have before retirement.
  • … your presentation is appreciated because you know the history of the problem well.
  • … or comments are made saying that your beard puts years on you.

All this does not happen to you at 65. All this occurs little by little, in an irreversible manner. It is biology. And worse for those who don’t get there.

That is why retiring at 65 is no more than an illogical convention bereft of justification. There are people who anxiously wait for retirement to be able to “do the things they like”. I don’t understand this idea of retirement at all. Maybe it’s because I don’t understand retirement with a set date (like an expiry date). Whatever the case, I don’t see the need to retire to do other things because I really like what I do.

A very different thing is to reject retirement and to hold onto the monopoly of space, time and ideas. A generational change over is essential. With time, we all tend towards stability and Darwin showed us that the more stable a system, the less possibility it has for survival. A stable system has little variability and therefore little capacity to respond to new situations. The limited capacity of response impedes adaptation and therefore leads us to the same future as that of the dinosaurs.

It is much more important to talk about a generational changeover than retirement. Some key ideas in my opinion are:

  1. No generation has the right to stipulate how their successors should live. Each generation has the right (and obligation) to live as they see fit.
  2. No generation has the right to leave the space they have occupied in a way that impedes successive generations to design it the way they think best.
  3. No generation has the right to prevent successive generations from moving forward at their own chosen speed. Each one can move forward at the speed they desire but there comes a time when generations that have more past than future cannot monopolise the fast lane on the motorway.
  4. There is no need to consider retirement as a “set date” although it is imperative to be clearly aware that natural evolution will lead us to gradual invisibility.
  5. Experience DOES NOT generate knowledge. Experience is very useful to identify patterns more quickly, to increase the “bank of solutions” or to carry out repetitive tasks with greater precision (although it won’t be long before machines beat us at this). What generates knowledge is curiosity, critical thinking and hard work (very hard work), in other words, perseverance.
  6. Each generation has the duty to explain what they have done and why they did that. They need to put this forward for general consideration. This should not be done to gain recognition but to be questioned so as to help learn from mistakes and to avoid others committing unnecessary reiterations.
  7. Naturally, no generation has the right to define the agenda that a succeeding generation needs to follow. Giving an opinion with a critical spirit, yes, always, but stipulating the itinerary based on experience is doing a great disservice to the generational changeover.

All this is not a justification for paralysis. There are always challenges in this process. It is always possible to find “blue oceans” on which to sail. Joaquim Mª Puyal has returned to the radio. I have not listened to him at all but I have read some declarations in which he stated that “at my age, a challenge is a luxury”. We can (should) look for challenges at any given time, but with the rules of the game in mind.

A friend of mine, Josep Mª Monguet, told me that he went to visit a friend of his who was very ill. He said that the man, now ill, had always been very active. When he saw him, my friend, using a stereotype said to him: “What are you up to these days?” “I think up concepts”, he replied. After all, you are very fortunate if you can still “think up concepts”.

Post written by Joan Escarrabill (@jescarrabill)

Shall we go an extra mile? The IMIM and IDIBELL place the patient at the centre of research

24 Jan
Maite Solans Domènech

Research impact assessment studies show that to achieve more impact on society the participation of ‘people that can provide value’ is an important factor. What these studies show us is that making key actors participate in the long process of research can improve the efficacy of its application and its impact on society. In the conference which AQuAS organised on Participation in Research last April 4, Derek Stewart, very much involved in Patient and Public Involvement and Engagement at the NIHR Nottingham Biomedical Research Centre, told us that participation provides different perspectives to research. In addition, Derek Stewart explained that “while patients have the opportunity to configure the future and make sense of what is happening to them in their day to day, researchers have the opportunity to legitimate what they do and make their results visible.”

So what have we learnt from all this? Firstly, that there is diversity of participation in research with a wide range of ways of interaction that are inserted in the different levels of the research process. Secondly, that despite individual idiosyncrasies, a global and shared approach is needed to avoid contradictions and to take advantage of mutual learning. Thirdly, that a commitment is needed on the part of all the different institutions and the research community in order to favour participation in research and to have an impact on society. This is why a Work Group on Participation in Research has been created, (#SomRecerca). Under the initial coordination of AQuAS, different health research institutions have come together to promote actions, agents or strategies that facilitate participation and that foster more awareness of the research community. The principles that accompany this group are based on mutual support and the acceptance that diversity and different realities exist within each context.

The first step taken by this group has been to hold conferences in two institutions (IMIM and IDIBELL), last 22 and 23 of January, under the title Shall we go one step further? Placing the patient at the centre of research. These conferences have been a good opportunity to present experiences that were already on the go within the institution itself which place the patient at the centre of research.

The conferences have made the different experiences stemming from individual motivations worthwhile, of researchers or users themselves, and they have been inspirational as examples of where one can start. The patient has been placed at the centre of research in these experiences: to obtain resources, to generate ideas, to prioritise research or to be a part of the research team, among others.

And more specifically, actions have been proposed that help develop the participation of patients which provides value in research:

  • Informing patients of the research that is being carried out in institutions; that is, bringing research closer to citizens
  • Communicative skills of the researcher towards a non-scientific audience
  • Effective communication channels between patients and researchers, be they via an associative network or via other activities or means of communication such as conferences with patients, etc…
  • Support for all those involved in participation: of recruitment, of time, of resources, between researchers or with a guide.
  • Stable work groups that include the participation of different profiles (basic and clinical researchers, assistants, managers and patients) so as to identify needs, come up with ideas or make proposals, for example.

In short, the synergies between patients and researchers must be sought out in those cases where value can be provided. It is not always and easy path but one which makes a whole lot of sense.

Post written by Maite Solans Domènech.

Medical tourism

17 Jan
Joan MV Pons

Those who have seen the British movie “The Best Exotic Marigold Hotel” (2012) will remember that one of the protagonists, a cantankerous old lady who saves the hotel thanks to her bookkeeping skills, goes to India to get a quicker treatment for arthroplasty although I can’t remember whether it was for a hip or knee replacement. It serves as another example of what is known as medical tourism which consists of precisely that, travelling to another country to find a health service more quickly or cheaply.

Barcelona is a centre of attraction for health tourism and several clinics and hospitals in the city advertise their services through the Barcelona Medical Center and the Barcelona Medical Agency, in a mix of hotel interests and prestigious professionals. The Catalan Tourism Agency itself includes this as an asset for a country. Not long ago, when there were doubts about whether there would be enough antiviral treatments of direct action to treat all people infected with the hepatitis C virus, some astute countries like Egypt, where tourism had dropped sharply for different reasons that have not gone by unnoticed, announced that for 5,900€-8,000€ you could spend one week in the country, have a stroll around the pyramids and at the same time receive treatment. It is worth mentioning that Egypt, due to its high prevalence of hepatitis C, has great expertise in this and is an undeniable tourist destination, even more so if we throw in a cruise along the Nile to boot.

We are not saying anything new regarding health tourism because even in the times of ancient Greece some temples in Asclepi had more attraction than others. It is a phenomenon which has been on the rise for quite a few years now even though it has been affected by economic recessions, like other businesses. We are talking about a medical tourism which is sensitive to quality and another more sensitive to cost; the first predominant among the affluent and the second among the middle class. No country seems to be protectionist in this field. In fact, quite the contrary and it is a form of importation (people who come looking for a health service with a short stay but which can easily be extended in the long term to pensioners that come looking for sea and sun in the last years of their lives). It could almost be considered as a form of foreign investment.

There are countries which, following Adam Smith’s recommendations, have specialised in a particular type of health tourism. Barcelona is well-known for its eye clinics, digestive surgery, transplants and assisted reproduction. In terms of transplantation, everyone knows that the trade in human organs is banned but no one doubts that in some countries it is done. Regarding assisted reproduction, the greater or lesser attraction of a country is largely determined by the degree of permissiveness in its legislation and as with other types of health tourism, by its costs. This legal issue becomes particularly apparent in what is known as surrogate pregnancy or surrogacy. It is said that this “industry” specifically, where a difference can be made between gestational surrogacy (embryos generated in vitro) and traditional methods (only artificial insemination), generates up to 6 billion dollars annually and that India is one of the main destinations. Needless to say, there are considerable ethical issues regarding both assisted reproduction and transplantation.

Besides what has already been mentioned, one can find a wide range of services abroad: all sorts of heart, bariatric or plastic surgeries, and also the more traditional treatments in health spas in exclusive locations (who does not think of “The Magic Mountain” by Thomas Mann). For those who see the world as a potential source of business, medical tourism can be a great investment and if tendencies today are anything to go by, it will continue grow even more in the future. It is also a very competitive field of business, especially in terms of prices as an international comparison of costs show.

Post written by Joan MV Pons.

Blog AQuAS Awards 2018

10 Jan

Avui fem públic qui és el guanyador del Blog AQuAS Awards 2018 que reconeix el post amb més lectures de l’any.

En aquesta edició, el premi es debatia entre cinc posts finalistes de Ferran Barbé, Olga Martínez, Xavier Mora, Núria Radó, Angelina González, Dolores Ruiz i Dolors Benítez.

El guanyador ha estat Ferran Barbé amb el següent post:

Moltes felicitats, Ferran!

Let’s begin the year…

3 Jan

We begin the year by giving thanks to all the people that have collaborated in the blog AQuAS during 2018: Ferran Barbé, Olga Martínez, Xavier Mora, Cari Almazán, Gaietà Permanyer, Dolors Benítez, Clàudia Pardo, Francesca Moya, Iria Caamiña, Núria Radó Trilla, Núria Cuxart, Glòria Novel, Jordi Varela, Ernest Abadal, Marta Millaret, Núria Rodríguez-Valiente, Marc Fortes, Mercè Salvat, Anna García-Altés, Marcel Olivé Elias, Jean Patrick Mathieu, Enric Limon, Gonçalo de Carvalho, Alícia Avila, Elisa Poses Ferrer, Ion Arrizabalaga, Joan MV Pons, Joan Escarrabill, Felip Miralles, Montse Moharra, Lina Masana, Mireia Espallargues, Xavier Bonfill, Marta Gorgues, Gemma Cabré, Jorge Arias, Johanna Caro Mendivelso, Kayla Smith, Angelina González Viana, Dolores Ruiz Muñoz and Ramon Maspons.

Many thanks to everybody!

Virtual reality, assessed reality

28 Dec

In recent years, the number of projects in innovation has increased exponentially. The presence of disruptive solutions has an impact on our day to day lives. From the use of mobiles and apps to that of robots and automation, the ecosystem of disruption has opened the way to a new paradigm: there are technological solutions which monitor and manage data of all types clearing the way for new scenarios.

With a transregional training and recruitment programme in the field of innovation, it will be possible to create a robotic continuum between the home environment and professional environments which will facilitate the adoption of innovation, individual preferences and HTA methodologies.

We are talking about the ecosystem of innovation and the ALEXHTA project.

The ALEXHTA project will develop a robot capable of writing HTA reports on any subject of interest, prioritised by the individual or community.

The next step (in its prototype phase at the moment) will be the AHTA algorithm (accelerated HTA). By means of a system of machine learning, it will create updated knowledge on demand based on previously written assessment reports and will synthesise the PICO question in a PCCO answer (Potent, Current, Compelling, Optimised) by also using information  published in real time using a virtual search engine in Pubmed/MEDLINE.

Once the most novel publications with the highest methodological quality on a subject have been identified, selected and summarised, this search strategy will be replicated on all sources of available information including scientific publications which as yet have not been elaborated but which already form part of the DNA of researchers. We are not talking about including pre-prints, but pre-thinks.

What is the aim of all this? Assess by innovating and accelerate by innovating (AI-AI). We will soon have more information about the ALEXHTA robot, developed by the main assessment agencies, which will no doubt become part of the everyday fabric of citizens’ lives in the future.

Happy Sants Innocents joke from AQuAS!

(Sants Innocents is the equivalent of April Fool’s Day in the English speaking world).

Season’s Greetings from the blog at AQuAS

20 Dec

From the AQuAS blog at the Catalan Agency for Health Quality and Assessment (AQuAS), we would like to thank you for having accompanied us yet another year.

With the aim of sharing knowledge and generating a space for thought, we have published 48 posts in 2018.

The editorial line of the blog deals with subjects of assessment and health systems, of the participation of patients and citizens, of low-value practices (Essencial project), of eHealth and connected health, of the analysis of data, of research, of gender questions, of inequalities in health, of innovation and of current affairs. The contents are produced by authors at the AQuAS and invited authors.

The five most read posts in 2018 have been the following (in alphabetical order of the title):

Next 10 January, we will discover the winning post of the Blog AQuAS Awards 2018. Till then, thank you very much for reading us and happy holidays!

Post by Marta Millaret (@MartaMillaret), editor of the AQuAS blog

PIPPI project: community of practice in procurement based on value

13 Dec
Ramon Maspons

Innovation has been present in the AQuAS blog with projects such as Antisuperbugs and Ritmocore but there are many more on the go right now. Today we put the focus on the purchase of innovation and on how this innovative methodology can have an impact on clinical practice.

We interview Ramon Maspons, engineer specialised in the management of innovation and technology, coordinator of innovation at AQuAS.

What tools does the health system at present have within its reach to add value to healthcare?

The public procurement of innovation is one of the facilitating instruments when adopting innovation and developing policies for technology and innovation. Due to the characteristics of the health sector this becomes a strategic element. There are other sectors where this does not happen because the public purchaser does not have market power.

In what way does innovation provide added value?

At a first level, we could say that if there is no application no value is generated. At a second level, I would say that the changes in the process are what add value. And at a third level, we could talk directly about the user.

A very brief article was published not long ago on this subject in the journal Annals de Medicina. Recently, in another context, the King’s Fund published a report on models of innovation.

Could you highlight an innovative project within the field of innovation?

Yes, the PIPPI project, coordinated by the Karolinska University Hospital in which AQuAS is involved, together with six other institutions in the hospital and university environment in Sweden, Holland, Italy, Austria, Spain, Finland and the United Kingdom. It is a platform made up of hospitals from the European Hospital Alliance, which is the network of the most relevant European hospitals, and then AQuAS. The focus of this work group is the new models of procurement based on value using digital technologies as an element to transform health services.

Work group of the PIPPI project

 

Have you considered changing the name of the project?

No, but in fact yes, because the name has curious meanings and connotations in different languages. This was one of the subjects that arose in the Kickoff meeting of the project.

Jokes aside, what is the involvement of AQuAS in the PIPPI project?

The expertise of AQuAS in assessment, innovation and the procurement of innovation is key. This project proposes an environment where the different stakeholders involved in change can come to an agreement and work together, both when revealing the needs of a health system, of hospitals, as well as when involving companies, technological centres, universities, patients and caregivers.

It is a very ambitious aim. What would you say is special about this project?

Its strategic focus of putting the different stakeholders involved in improving healthcare in the same project but having the support of the leadership of hospitals and an assessment agency. Identifying needs and solutions using this vast network of diverse expertise is one of the strengths of this project.

How will the PIPPI project work?

The project needs to develop a community of practice where challenges can be posed and solutions considered within an international framework.

Could you be a little more specific about which environments digital technologies will have an impact on in the health services?

By all means. We can include very different subjects such as co-creation with clinicians, telemedicine, data analytics, artificial intelligence, and so on. Some aspects are nearer on the horizon and others more distant. There exists a powerful reflection on digital technologies: it is said that everything that is digitalised is dematerialised and demonetised (it may be a subject too complex to go into here) and there are also those who say that, in the end, what is digitalised is democratised, but now that really would be going into other subjects.

Earlier you mentioned involving patients – who and what are we talking about exactly?

The patient is a key element in procurement based on value because the patient generates value and this is something difficult for other sectors to understand. When we talk of digital transformation, the involvement of patients is often as necessary as it is a sensitive issue and a certain methodology is therefore required, or specific game rules. We are talking about complex systems which require complex ways of working where, among other things, very diverse sensitivities, organisational models, governances, health systems or types of providers are involved. In short, what we are talking about is getting patients to become a part of identifying needs and taking decisions; we are talking about expert patient concepts, the participation of citizens and about health literacy.

And how are you going to achieve all this?

As members of this consortium, we have the experience, knowledge, methodologies and leadership to forge ahead with a project of this nature. I recommend looking at the presentation of Romualdo Ramos and Tanja Stamm of the Medical University of Vienna to know more about this project.

What is the aim of the PIPPI project in a few words?

Impossible in just a few words, but can I do it in nine? Facilitating the joint design of the best healthcare possible.

The importance of registries in 4 questions

15 Nov
Kayla Smith

In this AQuAS blog post we’ll continue talking about registries. Last month Jorge Arias focused on registry collaboration between clinics and researchers, and at the beginning of the year we touched on the same topic during interviews with Olga Martínez and Xavier Mora, where the focus was on arthroplasties and new materials used in protheses. A few years ago, in 2015, we celebrated 10 years of the Catalan Arthroplasty Register (RACat), managed and coordinated by the Agency for Health Quality and Assessment of Catalonia (AQuAS). In that post, Olga Martínez and Laia Domingo discussed the experience of the registry as a whole, in terms of history and function.

We’ll start today’s post with the importance of registries.

1. What do we mean by ‘registry’?

A registry is a collection of standardized information that can range from patient diagnoses, outcomes, procedures, diseases, device performance, among other aspects, and uses this data to evaluate specific outcomes for predetermined clinical, scientific, or research purposes.

More concisely, a registry collects standardized information, to be used for a specific purpose, about patients who share a condition or certain characteristics. Patient registries have existed for decades, with the first arthroplasty registries, in the Nordic region, making their debut in the 1970s: the Swedish Hip Arthroplasty and the Swedish Knee Arthroplasty Registers, in 1975 and 1979, respectively, followed by the Finnish Arthroplasty Registry in 1980.

This post will focus specifically on implant registries and their importance at the local, national, and international levels, though other types of registries exist.

2. Why are they important?

Registries are of vital importance for a number of reasons.

In terms of the health sector, since a standardized set of data is collected, a registry enables health professionals and researchers to make systematic comparisons across multiple datasets and traverse geographic locations. Healthcare personnel are kept abreast of other variables that different registries take into account and they can draw conclusions based on the experiences of others. Registries can facilitate professional development while simultaneously bringing clinical practices, outcomes, and possible areas of improvement to light.

With this data, we can highlight best practices, using previous outcomes as a guide, as well as glean important information, quickly, if a need arises for implant recalls.

A brief example focuses on Poly Implant Prothèse (PIP) breast implants, which were made in France from a cheaper, industrial-grade silicone that was not approved for medical use. The implants were rupturing twice as frequently as the industry average and causing health problems in thousands of women.

Following this occurrence, the NHS created and implemented a register, The Breast and Cosmetic Implant Registry (2016), for patients in England with breast and other cosmetic implants that allows them to be traced quickly and efficiently, should any similar safety concerns arise.

3. Strengths and barriers of international registries?

Registries are not only important when keeping track of information at the local or national levels, they are also extremely helpful in an international context as techniques and methods can be easily shared among countries.

However, certain barriers can play a part in international data access. Recent changes in European law, specifically in terms of patient data protection, could have effects on international registries.

According to an expert with the Dutch Arthroplasty Register (LROI), these laws, introduced in May 2018, could be detrimental to registries whose national regulations are flexible and who are now forced to adapt to more rigid regulations.

In terms of the personnel involved in international registries, whether they are stakeholders, policy makers, healthcare professionals, or others, they have to keep abreast of potential barriers resulting from encompassing multiple countries as well as other regulatory aspects at the regional, state, and European levels to ensure correct implementation and functioning of the registry itself.

Experts from two international registries, the Nordic Arthroplasty Register Association (NARA) and the International Collaboration of Breast Registry Activities (ICOBRA), have both stated that multiple countries, and thus multiple jurisdictions, participating in a single registry could prove difficult, given that the registry as a whole is obliged to function using the regulations imposed by the strictest country.

Though there could be a few barriers to international registries, they continue to be a fountain of useful information. They facilitate advancement in knowledge, processes, and data regarding types of implants to use and/or avoid.

4. What can this knowledge do for AQuAS?

Registry implementation, long-term functionality, and best practices are of great importance to AQuAS, who created and is in charge of the RACat, the Catalan Arthroplasty Register.

The RACat currently collects information on hip and knee arthroplasty procedures from 53 out of 61 health centers in the Integrated Healthcare System of Public Healthcare Network of Catalonia (SISCAT), and is on the cusp of including shoulder arthroplasty procedures.

Given the breadth and depth of existing knowledge in the international community, AQuAS, and those involved closely with the RACat, are interested in the information available in terms of best practices for implementation and sustainability, as well as the types of variables that other registries collect.

With the ability to follow in the footsteps of registries that are already well established, AQuAS, the Catalan health system, and the international community as a whole, can improve the care given to their respective populations.

Post written by Kayla Smith.

Preventing overdiagnosis 2018: Three key points to reduce overdiagnosis

8 Nov
Johanna Caro Mendivelso

This year, the annual Preventing Overdiagnosis conference was held in Copenhagen, co-sponsored by the World Health Organisation, where delegates from about 30 countries attended.

The space generated in this conference provides the opportunity to approach the subject of how health professionals, researchers and patients can implement solutions to problems related to overdiagnosis, overtreatment and overuse by using the evidence available.

Overall, some of the subjects discussed were the implementation of recommendations to “stop doing”, the challenge of dealing with excessive diagnosis in clinical visits, the impact of overdiagnosis, the fact of converting citizens into patients and the role of risk factors in excessive diagnosis.

John Brodersen, professor of family medicine at the University of Copenhagen, started the conference by making a reflection on what is and what is not overdiagnosis. In general, overdiagnosis means turning people into patients unnecessarily by identifying problems that were never going to cause harm or by medicalising ordinary life through expanded definitions of diseases. This overdiagnosis can trigger a cascade of excessive treatments.

Later, Iona Heath, general practitioner and member of the Organising Committee of Preventing Overdiagnosis, asked the audience the question Why are we so afraid of normal? She reflected on why doctors are willing to rush into a diagnosis and pointed out that the task of defining “who is normal” is a challenge. Who should define who is normal and with what criteria?

Gisle Roksund, general practitioner in Norway stated that the general tendency in medicine is: “find it as soon as possible and do more”. Similarly, he pointed out that people are being labelled as ill with “pre” conditions when they are not. And he ended off by saying that life itself is a “pre-mortality” condition.

On his part, Paul Glasziou, general practitioner and professor at the Bond University in Australia, presented three key points to reduce overdiagnosis: reducing over-detection, over-definition and medicalisation. Juan Pablo Brito, endocrinologist and researcher at the Mayo Clinic, talked about a new term in his conference on diagnosis centred on the person: Extradiagnosis: when the diagnosis is not appropriate for the biology, context or preferences of a patient. The diagnosis centred on the patient is based on identifying the problem and carrying out actions to find the solution. That is, “reaching a conclusion together which makes intellectual, emotional and practical sense”.

In mental health, Allen Frances, psychiatrist in the United States, highlighted that overdiagnosis in psychiatry could be avoided if general practitioners had more time in their visits to get to know their patients better.

On the other hand, Steven Woloshin and Lisa Schartz, general internists and co-directors of the Center for Medicine and Media at The Dartmouth Institute, explained that some advertising campaigns could broaden the definition of diseases which can lead to an overdiagnosis and a medicalisation of life experiences. These reflections highlight the importance of having regulation related to these campaigns.

Lastly, the Preventing Overdiagnosis is a space which allows for the sharing of experiences, both theoretical and practical, of what is being done in the world with regards overdiagnosis and overtreatment.

From the AQuAS, and in collaboration with health professionals and scientific societies, the Essencial project in Catalonia tries to address these issues by contextualising them in our environment and by trying to implement recommendations that avoid low value practices and in consequence, an overuse.

Post written by Johanna Caro Mendivelso (@jmcaro103).