A randomized trial comparing transanal irrigation and percutaneous tibial nerve stimulation in the management of low anterior resection syndrome.

AIM: To assess the effectiveness of transanal irrigation (TAI) compared with posterior tibial nerve stimulation (PTNS) in severe and chronic low anterior resection syndrome (LARS). METHOD: A two-group parallel, open-label randomized controlled trial carried out in a single university hospital. The study population included patients with a LARS scale score of more than 29 points who had undergone rectal surgery more than 1 year previously. These were randomly allocated, with a central randomization system, following a 1:1 sequence to TAI or PTNS. The main study outcome was to achieve a reduction of at least one LARS grade in at least 50% of the patients, for each intervention. RESULTS: A total of 27 patients (TAI = 13, PTNS = 14) were randomized. Both groups were similar with regard to confounding factors. Four patients were excluded because of intercurrent disease or early dropout, leaving 23 (TAI, n = 10; PTNS, n = 13) for analysis. Eight out of 10 and 4 out of 13 patients were downgraded with TAI and PTNS, respectively. The median LARS score decreased from 35 [interquartile range (IQR) 32-39] to 12 (IQR 12-26) (P = 0.021) for the TAI group and from 35 (IQR 34-37) to 30 (IQR 25-33) (P = 0.045) for the PTNS group. The Vaizey score fell from 15 (IQR 11-18) to 6 (IQR 4-7) (P = 0.037) and from 14 (IQR 13-17) to 9 (IQR 7-10) (P = 0.007) with TAI and PTNS, respectively, with 80% and 38% of patients, respectively, showing decreases of more than 50%. Improvement in quality of life was observed in both groups. CONCLUSION: Both treatments improved the LARS score in this study but this was only significant in the TAI group.

Efficiency of a self-administered outpatient parenteral antimicrobial therapy (s-opat) for infective endocarditis within the context of a shortened hospital admission based on hospital at home program.

OBJECTIVE: This study aimed to evaluate the efficiency of treatment of infectious endocarditis (IE) via Self-administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) supported by a shortening hospital admission program in a hospitalization-at-home unit (HAH), including a short review of the literature. METHODS: Ambispective cohort study of 57 episodes of IE in 54 patients treated in an HAH unit between 1988 and 2014 who receive S-OPAT after prior intra-hospital clinical stabilization. Characteristics of each episode of IE, safety and efficiency of the care model, were analyzed. RESULTS: Forty-three (76%) patients were males with a median age of 61 years (SD = 16.5). A total of 37 (65%) episodes affected the native valve (42% the aortic valve). In 75%, a micro-organism was isolated, of which 88% were Gram-positive bacteria. No deaths occurred during HAH program, clinical complications appeared in 30% of episodes, only 6 patients were re-admitted to hospital although no patient died. In the 12 months' follow-up 3 cases had a recurrence. The average cost of a day stay in HAH was €174 while in traditional cardiology hospitalization was €1100. The total average cost of treatment of each episode of IE managed entirely in hospital was calculated as €54,723. Application of the S-OPAT model based on HAH meant a cost reduction of 32.72%. CONCLUSIONS: In suitably selected patients, treatment of IE based on S-OPAT supported by a shortening hospital admission care program by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

Sistema de vigilancia epidemiológica comunitaria bonis: estado actualy proyecciones futuras / Community epidemiological surveillance system bonis: current status and future projections

El sistema actual de vigilancia epidemiológica en la zona del Centro de Ayuda Mutua y Salud para Todos (CAMSAT) del Bañado Sur, de Asunción, se basa en la búsqueda rutinaria de posibles casos febriles mediante visitas domiciliarias, realizadas por las agentes comunitarias adscritas a la Unidad de Salud Familiar (USF). Cada una de las diezagentes comunitarias de CAMSAT tiene asignada 150 hogares, y los resultados de susvisitas domiciliarias quedan recogidos en planillas que se reportan mediante medios tradicionales (papel, correo interno, fax, etc.) a la DGVS del Ministerio de Salud. La consecuencia de este modo de trabajo es que muchas veces las acciones de bloqueo de la transmisión llegan tarde con el coste social y económico que ello significa. El sistema Bonis introduce la telefonía móvil como elemento catalizador para transformar la búsqueda rutinaria de posibles casos febriles en una acción proactiva, y también la utilización de tecnologías web y bases de datos para el registro de pacientes y su correspondiente seguimiento por el personal sanitario. La utilización de estas tecnologíasde la información y comunicación (TICs) transforman el sistema de vigilancia epidemiológica en un caso de estudio de e-Salud en Paraguay. Se describe el estado actual y proyecciones futuras del sistema de vigilancia epidemiológica comunitaria “Bonis”,que utiliza las TICs para prevenir, alertar, supervisar y controlar la expansión de síndromes febriles en un área de influencia del Hospital Barrio Obrero (HBO), en la Unidad de Atención Primaria en Salud del Centro de Ayuda Mutua y Salud para Todos, Asunción,Paraguay.

The current system of epidemiologic surveillance in the area of Mutual Aid Centre and Health for All (CAMSAT in Spanish) in the “Bañado Sur” in Asuncion is based on routine screening of possible febrile cases through home visits made by community agents fromthe Primary Health Care Unit (USF in Spanish). Each of the ten community agents are assigned to 150 households and the results of these home visits are recorded on sheets that are reported through traditional means (paper, internal mail, fax, etc.) to the DGVSof the Ministry of Health. The consequence of this working system is that often the blocking actions arrive late with the social and economic costs that this implies. The Bonis system uses the mobile phone as a catalyst to transform the routine screening ofpotential feverish cases in a proactive action and the web technology and databases for patient records and appropriate follow-up by health personnel. The use of theseinformation and communication technologies of (ICTs) transforms the Epidemiological Surveillance System in a study case of e-Health in Paraguay. This document describes the current status and future projections of the community epidemiological surveillancesystem Bonis which uses Information and Communication Technologies (ICTs) to prevent, warn, monitor and control the spread of febrile syndromes in a catchment area of Barrio Obrero Hospital (HBO), Unit of Primary Health Care Center Mutual Aid and Health for All, Asuncion, Paraguay.

Embarazo como factor de riesgo de hospitalización y muerte en la pandemia por influenza A (H1N1) en Paraguay / Pregnancy as a risk factor for hospitalization and death during influenza A (H1N1) pandemic in Paraguay

La influenza A (H1N1) se ha identificado como la causa de epidemia de Infección Respiratoria Aguda en Paraguay y en el mundo. Se analizaron los factores de riesgo asociados a la morbimortalidad en embarazadas con sospecha de infección por H1N1 notificadas a la Dirección General de Vigilancia de la Salud (DGVS) del MSPBS durante los primeros cuatro meses de la pandemia, en comparación con mujeres en edad fértil no embarazadas con sospecha de infección por H1N1. A partir del 28 de abril de 2009, la DGVS comenzó sistemáticamente la vigilancia de H1N1 en todas sus unidades notificadoras, siendo la notificación inmediata y por planilla individual basándose la notificación en la definición de casos confirmado establecidas por el país. Hasta el 25 de agosto del 2009 fueron notificadas 2268 mujeres con sospecha de H1N1, de las cuales 1120 tenían entre 15 a 40 años, y de ellas 117 estaban embarazadas. El 68% (79/117)de las embarazadas requirió hospitalización y la mortalidad fue de 21% (25/117), mientras que en grupo de las no embarazadas el 21% se hospitalizó (288 /1003) y la mortalidad fue de 1,5% (16/1003). Todos los casos fallecidos desarrollaron Infección Respiratoria Aguda Grave caracterizado por un síndrome de distrés respiratorio que en algunos casos requirieron asistencia respiratoria mecánica (ARM). Ninguna de las embarazadas refirió antecedente de co-morbilidad. El 22% (26/117) de las embarazadas y 2,9% (30/1003) de las no embarazadas recibieron Oseltamivir como tratamiento. Se evidencian que la infección produce alta morbimortalidad en embarazadas en comparación con mujeres del mismo grupo de edad, los cuales apoyan la recomendación de un tratamiento antiviral precoz en gestantes, así como un seguimiento clínico cercano.

Influenza A (H1N1) has been identified as the cause of the Acute Respiratory Infection epidemic in Paraguay and the world. Risk factors associated to morbid-mortality in cases of pregnant women with suspicion of H1N1 infection and notified to the General Direction of Health Surveillance (DGVS in Spanish) of the Ministry of Public Health and Social Welfare (MSPBS in Spanish) during the fourth first months of the pandemic were analyzed in comparison to non-pregnant fertile women with suspicion of H1N1 infection. From April28, 2009 the DGVS started a systematic surveillance of H1N1 in all its notifying units, being the notification immediate and by individual spreadsheet basing the notification inthe case definition established by the country. Until August 25, 2009 2,268 cases of women with suspicion of H1N1 were notified, 1,120 of them were between 15 to 40 years and from them 117 were pregnant. Sixty eight percent (79/117) of the pregnant women required hospitalization and mortality was 21% (25/117) while in the non-pregnant women, 21% were hospitalized (288 /1003) and mortality was 1.5% (16/1003). All deceased cases developed Serious Acute Respiratory Infection characterized by a respiratory distress syndrome that, in some cases, required mechanical respiratory assistance (MRA). None of the regnant women referred history of co-morbidity. Twenty two percent (26/117) of the pregnant women and 2.9% (30/1003) of the non-pregnant women received Oseltamivir as treatment. These results show that the infection produces high morbid-mortality in pregnant women in comparison to women of the same age group, supporting the recommendation of an early antiviral treatment in pregnant women as well as a close clinical follow-up.

Cutaneous metastases of hepatocellular carcinoma.

Cutaneous metastases are an unusual finding that may present as the first sign of an internal neoplasia. A case of cutaneous metastases of hepatocellular carcinoma, which may often involve other organs but very rarely metastases to the skin, is reported.