Evidence-based guides in tracheostomy use in critical patients. / Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico.

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Locally advanced breast implant-associated anaplastic large-cell lymphoma: a combined medical-surgical approach.

OBJECTIVE: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare form of non-Hodgkin's T-cell lymphoma that develops around breast implants. CASE PRESENTATION: This report illustrates the case of a patient affected by a locally advanced BIA-ALCL which infiltrated the thoracic wall (stage T4N0M0) following implant-based reconstruction after left mastectomy. Given the initial inoperability due to the patient's poor general condition, the treatment plan provided for a primary cycle of systemic neoadjuvant immunotherapy/chemotherapy, surgical removal of the mass, and subsequent systemic chemotherapy/immunotherapy. This resulted in complete remission - the patient remained disease-free even over a year later - without the need for adjuvant radiotherapy. CONCLUSIONS: Our real-life case shows how the existing guidelines can be successfully adapted as part of an individualized approach to advanced and/or difficult cases.

Overexpression of bcl-2 alters usage of mutational hot spots in germinal center B cells.

Bcl-2 is an anti-apoptotic gene important in B cell development. In order to study how apoptosis regulates somatic hypermutation and selection of B cell clones in the germinal center, we examined the antibody response to phosphorylcholine (PC) in transgenic mice overexpressing bcl-2 in the B cell compartment. The anti-PC antibody response is dominated by the S107V1 variable region heavy chain gene. We, therefore, analyzed S107V1-encoded heavy chains from germinal center cells. The proportion of germinal center sequences that were mutated, and the frequency of mutations did not differ significantly between the two groups of mice. No significant differences were found in the clustering of replacement mutations in the complementarity determining regions (CDRs) and in replacement to silent (R:S) mutation ratios. A significant difference between bcl-2 transgenic mice and controls, however, was found in the targeting of mutations to oligonucleotide motifs presumed to be mutational "hot spots." While non-transgenic mice displayed the expected clustering of mutations in hot spots, mutations from bcl-2 transgenic mice lacked this pattern. This observation suggests that the mechanism for somatic hypermutation includes two distinct functions, a non-specific mutational apparatus and a mechanism to target mutation to hot spots, and that in certain circumstances these functions may be uncoupled.

The Danish approach to standards for economic evaluation methodologies.

Standards for economic evaluation have now been proposed in several countries. The background for this article is a report commissioned in 1994 by the Danish health authorities (the National Board of Health and the Danish Ministry of Health) on the state of the art of economic evaluation: are the methods ready to be used for systematic decision-making in the Danish healthcare sector? The themes of this article are the attitude towards economic evaluation of medical technologies and healthcare services in Denmark, the areas for application and the desirability and feasibility of a standard set of methods for conducting economic evaluations. In addition, the current state of methodologies in economic evaluation is briefly outlined. On the background of a roundtable discussion of interested parties, the Danish health authorities have decided to introduce economic evaluation of new pharmaceutical products, on a voluntary basis for 2 to 3 years, when application has been made for public reimbursement.

The role of economic appraisal in Denmark.

The numbers of economic appraisals conducted have been increasing during the last ten years in Denmark. This article involves 17 economic appraisals on specific health issues. Most of the studies use the cost-effectiveness approach. Cost appraising has only been conducted in five of the studies, three use the cost-benefit approach, and only one uses the cost-utility approach. Most of the studies have been directed at the policy level and only five have been directed at the clinical decision making level. The success of the individual economic appraisals is being assessed by looking at their ability to change behaviour among the decision makers according to the results obtained and by looking at their ability to enter the decision making process. However, as this article stresses, economic appraisals have also been used to introduce the economic appraisal approach as a way of thinking, as a road to efficiency, within the health services. This has led to the incorporation of economic appraisals into committee work at the National decision making level, the issuing of guidelines to local health authorities including efficiency, and to some acceptance of the efficiency term among health professionals.

Economic evaluation of programmes aiming at eradicating infectious diseases.

The subject of this article is to discuss the global and regional economic aspects of programmes for eradicating infectious diseases. The perspective on the issue is that scarce health care resources should be employed in the best possible way. The task is then to examine what the best possible use might be. A starting point is by asking the relevant policy questions attached to eradications: Is there a suitable technique, what are the costs, and what are the benefits? Of particular importance is the opportunity cost of using resources on eradication when other health care problems may require more urgent donation of resources. The paper attempts to set up a generic model for economic evaluation of eradication programmes. But, as there are many different treatment strategies varying from one country to another, such a generic model may need modifications to suit a particular strategy. However, the paper is contextual and should only be viewed as guidance for those wishing to conduct an economic analysis of eradication programmes, or as a initiative to create discussion among health care decision makers.

Hospital comparisons using a Euro Health Data Base for resource management and strategic planning.

A European approach for resource management and strategic planning has been implemented in the HOSCOM project of AIM by defining information standards needed across countries, as well as a methodology to measure resources and costs at the institutional and interinstitutional level. A Euro Health Data Base (EHDB) has been obtained in order to test data availability and comparability as well as to validate models through macrocomparisons using case-mix (DRG's, refined grouping, disease staging) and microcomparisons based on three diseases (cardiac valve replacement, diabetes mellitus and hip fracture). The EHDB's presently based on 274 164 medical record summaries sampled from 7 countries allowed us to build prototypes (using Clipper, Prolog and SQL) in order to export uniform aggregates in the different countries, with standard software tools for statistical comparisons. It showed the present feasibility of using case-mix based on the European Minimum Basic Data Set (MBDS) and the difficulty of obtaining uniform data on resources and costs other than length of stay across countries. Medical data confidentiality was assured but not yet population-based representativity. Given the present state of the EHDB, problems have been clearly identified in order to be solved by international research and development projects in the near future.

[The value of life and limb]. / Vaerdien af liv og lemmer.

Assessment of the value of life and limbs is a controversial subject, not only emotionally but also theoretically. The economic starting point is based on assessment of the value of reduction or increase of the probability for an event which leads to disability or death. No concern is expressed for the single individual but for the phenomenon of probability where the person or persons who are affected by an event cannot be identified. Assessment of the value is in monetary units. The obvious discrepancy between the expression "value of life and limbs" and the theoretical content of the analysis has involved many misunderstandings. Attempts are made to elucidate and explain these. There is e.g. another method of assessing the value of life and limbs, the human capital method. In this, the disability and the premature death (compared with the current time) by means of loss of occupational income are assessed. The method is criticized and is discarded on the basis of theoretical arguments and consequences, the calculations of which are employed. Unfortunately, it has proved tempting to employ the method because it is relatively easy to make the calculations. Finally, the parts played by some recent questionnaire methods for assessment of alterations of risks are discussed. Assessment of the value of alterations in risks is an important requirement in order to carry out relevant cost-benefit analyses in the health sector. In cases where this is not possible, these analyses are meaningless.

[Costs and cost analysis]. / Omkostninger og omkostningsanalyse.

The costs of an activity is frequently the most conspicuous part in decision making when changes in health care services are considered. It is thus essential to be aware of the principles and considerations underlying the composition of costs. The concept of cost is not restricted to expenditures that have to be paid. It involves the notion of opportunity cost i.e. the cost of a service is the satisfaction or benefit foregone in not being able to use the resources involved to obtain some other service which is also desirable and therefore also provides satisfaction. Strictly, this relates to the best alternative way of using the resources. In order to estimate the costs of an activity, all costs, whether direct or indirect, tangible or intangible, ought to be taken into account. The fact that they may be difficult to measure a value is no excuse for ignoring them. In a cost analysis the result has to be assessed in the light of the types of costs employed and the aim of the analysis. Average cost is very often used, but is seldom the relevant costs. What is normally of concern is the cost of some change. Only by using marginal costs i.e. those costs that actually do change is it possible to obtain a true picture of resource consequences of that change. Regardless of the type of cost it is necessary to consider on whom the costs fall and to whom the benefits accrue. These may not be the same.

[Utilization of health care system by patients with chronic pain who apply for disability pensions. A registry study]. / Forbrug af sundhedssystemet hos kroniske smertepatienter der søger førtidspension. En registerundersøgelse.

INTRODUCTION: Patients with chronic pain may be awarded a disability pension if their working capacity is reduced as a result of an illness. Patients with chronic pain very often consult several specialists in order to obtain proof of their illness. The aim of this study was to investigate how an application for disability pension affected the utilization of health care services by patients with chronic pain. METHOD: Patients with chronic pain who applied for a disability pension in 1989 and 1990 were entered. The study period was divided into three: the year preceding the submission of the application for a disability pension, the time from submission of the application to the making of the decision, and the year following the decision of the health authorities. The patients were divided into four subgroups according to whether the disability pension was awarded or rejected, and whether the patients accepted or appealed the decision. The total costs of care in the primary sector were calculated on the number of and charges for visits to GPs and the total costs of hospital care were calculated on the number of bed days, visits to outpatients clinics, operations, and investigations. RESULTS: Patients with chronic pain had a significantly lower health care utilisation after the case has been closed. Those who did not get a disability pension and those who were not satisfied with the level of the disability pension, continued their utilisation of health care after the decision. The mean health care used by patients who appealed the level of the disability pension was three times higher than that used by patients who accepted the level of the disability pension. CONCLUSION: The study indicates that lack of or insufficient economic compensation from the social system in patients with chronic pain may contribute to inexpedient behaviour leading to increased costs to the health care sector.

[What is healthy economy?]. / Hvad er sundhedsøkonomi?

Health economics is the branch of economics which is concerned theoretically and practically with the health sector and related subjects such as e.g. the market for medicine and medico-technical equipment. In health economics, the universal basic problem is: Distribution of scarce resources to competing ends and establishment of rules for this. In this respect, (health) economics is knowledge about priorities based on the methodical an appreciative basis of economics. The essence is the absolute or relative scarcity and the existence of alternative uses for the limited resources. Many identify health economics with societal economic analyses: cost-benefit analyses or cost-effectiveness analyses. A great many analyses of this type have been published and these have been employed to an increasing extent in connection with decisions about introduction or alteration of the existing therapeutic or diagnostic methods. Health economics is, however, much more: theoretical and empirical analysis of the demand for health and health services, including the effect of payment-for-service; supplier and producer behaviour including questions about the existence and consequence of supplier-induced demand i.e. the professional health groups may, themselves, determine the extent of the demand and employment for their services to a considerable extent. Analyses of productivity and effectiveness and methods for measuring and assessing health status are two other typical subjects. Thus, in the course of the past 15-20 years, health economy has become established as an academic subject with its own professorships and scientific journals.

[What is cost benefit analysis?]. / Hvad er costbenefitanalyse?

The practical and theoretical bases of cost-benefit analysis are reviewed systematically with particular emphasis on how an analysis can be carried out in practice. A Danish analysis about introduction of vaccination for mumps, measles and German measles is included as a common example. The great significance of elucidating the socio-economical questions to be answered before commencing an analysis is emphasized. It is therefore recommended that, among other things, as a side-effect of the actual cost-benefit analysis, a cash-analysis and a budget analysis should be carried out to identify the parties involved in the immediate expenses and incomes. This is particularly important in the cases where the same parties have a central position in the decision-making processes concerned in the project. In addition, costs and benefits are frequently distributed differently in time in different ways: Short-term expenses and long-term benefits. In connection with decision-making, this may also involve problems and should, therefore, be elucidated in detail. Similarly, the importance of including many alternatives in the analysis is emphasized and illustrated. In conclusion, it is demonstrated how well the theoretical principles have been followed, the employment and the process which led to the concrete analysis.

[What is cost effectiveness analysis?]. / Hvad er costeffectiveness analyse?

Cost-effectiveness analysis (CEA) is an established economical form of analysis which, in public services, replaces the marketing mechanism. The questions which CEA attempts to answer are: Which form of medical technology is most economically effective where a given disease is concerned. Where and how must the medical technology be commenced. Which group of patients can benefit from a given form of medical technology? It is a prerequisite for employment of CEA that there is unanimity in advance about the object of an activity, eg. a given treatment or procedure in the diagnostic investigation. Several strategies may be employed to ensure that the aim is sufficiently wide: the limits may be explicit; goals may be established which compare years of life with quality of life, or several goals may be present in the goal. The predominant economical expression in CEA is alternative costs which must be sacrificed in order to carry out a certain activity. In order to estimate what is obtained by carrying out an activity, an expression of effect is essential. These are most frequently both of quantitative and also of qualitative character and may be subdivided into three categories: Alterations in the employment of resources. Alterations in production by society. Alterations in the conditions of health of the individual. Doctors are important decisions-makers and distributors of resources in the health services. The questions which a CEA can provide graduated answers to, are the questions that the doctor works with in clinical practice.(ABSTRACT TRUNCATED AT 250 WORDS)

[A review of the types of economic analyses of the health economy]. / Oversigt over økonomiske analysetyper i sundhedsøkonomien.

Great confusion is involved concerning health economics analyses. For example: What is the difference between cost-benefit and cost-effectiveness analyses? Is there a difference between the so-called cost-of-illness analyses? What is a financial analysis? These questions are discussed on the basis of the underlying economic theory and the use of the analyses. In order to avoid terminological confusion, the English terminology is retained. Cost-benefit and cost-effectiveness analyses are social economical analyses because they are all-embracing as regards what is understood by costs and profits based on the so-called welfare economy where cost-benefit analyses are concerned. The theoretical basis for cost-effectiveness analysis is slightly more obscure. Where both forms of analysis are concerned, no concern is shown for who obtains the profits or who pays the costs, i.e. a cross-sectional perspective. The financial analysis contrasts with this because attention is focussed directly on expenditures and revenues and the accounts responsible for the expenses and which obtain the revenues. The cost-of-illness analysis is a confusing but frequently employed and quoted form of analysis where an attempt is made to calculate the costs of a certain disease or injurious agent (alcohol, tobacco, accidents) for the various parties involved. These are subdivided into direct costs, roughly corresponding to the costs of treatment and indirect costs which include e.g. loss of income resulting from the illness, disability or death. This form of analysis is strongly warned against as the results of analysis may easily be misused frequently with absurd implications.

Self-assembled titanium calcium oxide nanopatterns as versatile reactive nanomasks for dry etching lithographic transfer with high selectivity.

We report the simple preparation of ultra-thin self-assembled nanoperforated titanium calcium oxide films and their use as reactive nanomasks for selective dry etching of silicon. This novel reactive nanomask is composed of TiO(2) in which up to 50% of Ti was replaced by Ca (Ca(x)Ti(1-x)O(2-x)). The system was prepared by evaporation induced self-assembly of dip-coated solution of CaCl(2), TiCl(4) and poly(butadiene-block-ethylene oxide) followed by 5 min of thermal treatment at 500 °C in air. The mask exhibits enhanced selectivity by forming a CaF(2) protective layer in the presence of a chemically reactive fluorinated plasma. In particular it is demonstrated that ordered nano-arrays of dense Si pillars, or deep cylindrical wells, with high aspect ratio i.e. lateral dimensions as small as 20 nm and height up to 200 nm, can be formed. Both wells and pillars were formed by tuning the morphology and the homogeneity of the deposited mask. The mask preparation is extremely fast and simple, low-cost and easily scalable. Its combination with reactive ion etching constitutes one of the first examples of what can be achieved when sol-gel chemistry is coupled with top-down technologies. The resulting Si nanopatterns and nanostructures are of high interest for applications in many fields of nanotechnology including electronics and optics. This work extends and diversifies the toolbox of nanofabrication methods.

All-silica nanofluidic devices for DNA-analysis fabricated by imprint of sol-gel silica with silicon stamp.

We present a simple and cheap method for fabrication of silica nanofluidic devices for single-molecule studies. By imprinting sol-gel materials with a multi-level stamp comprising micro- and nanofeatures, channels of different depth are produced in a single process step. Calcination of the imprinted hybrid sol-gel material produces purely inorganic silica, which has very low autofluorescence and can be fusion bonded to a glass lid. Compared to top-down processing of fused silica or silicon substrates, imprint of sol-gel silica enables fabrication of high-quality nanofluidic devices without expensive high-vacuum lithography and etching techniques. The applicability of the fabricated device for single-molecule studies is demonstrated by measuring the extension of DNA molecules of different lengths confined in the nanochannels.

Evidence-based guides in tracheostomy use in critical patients

Objetivos: Proporcionar guías de traqueostomía para el paciente crítico, basadas en la evidencia científica disponible, y facilitar la identificación de áreas en las cuales se requieren mayores estudios. Métodos: Un grupo de trabajo formado con representantes de 10 países pertenecientes a la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva y a la Latin American Critical Care Trial Investigators Network(LACCTIN) desarrollaron estas recomendaciones basadas en el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). Resultados: El grupo identificó 23 preguntas relevantes entre las 87 preguntas planteadas inicialmente. En la búsqueda inicial de la literatura se identificaron 333 estudios, de los cuales se escogieron un total de 226. El equipo de trabajo generó un total de 19 recomendaciones: 10 positivas (1B = 3, 2C = 3, 2D = 4) y 9 negativas (1B = 8, 2C = 1). En 6 ocasiones no se pudieron establecer recomendaciones. Conclusión: La traqueostomía percutánea se asocia a menor riesgo de infecciones en comparación con la traqueostomía quirúrgica. La traqueostomía precoz solo parece reducir la duración de la ventilación mecánica pero no la incidencia de neumonía, la duración de la estancia hospitalaria o la mortalidad a largo plazo. La evidencia no apoya el uso de broncoscopia de forma rutinaria ni el uso de máscara laríngea durante el procedimiento. Finalmente, el entrenamiento adecuado previo es tanto o más importante que la técnica utilizada para disminuir las complicaciones.(AU)

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.(AU)

Sistema robótico guía para la inserción de tornillos en cirugía de fijación de columna / Robotic Guide System for Insertion of Screws in Spinal Fixation Surgery

El presente artículo muestra el diseño y operación de un primer prototipo de robot para la guía en la inserción de tornillos en cirugía de fijación de columna. Este tipo de cirugía, realizada normalmente de forma manual, puede producir muchas lesiones debido a errores humanos al momento de introducir los tornillos en las vértebras del paciente. Para evitar dichos errores se puede utilizar la tomografía computarizada, pero los resultados son mucho mejores si un robot asistente proporciona al cirujano el camino para la inserción del tornillo, según la imagen del tomógrafo. Este artículo muestra como utilizando un robot comercial de bajo costo se puede implementar un sistema que provee una solución funcional a este problema. Se implementó un software que permite definir la posición inicial y final del tornillo a ser introducido, sobre la imagen Dicom del paciente. Con esta información el sistema mueve el robot el cual posee un anillo que guiará al cirujano en la inserción final. Los resultados muestran un sistema bastante preciso ofreciendo al cirujano un camino seguro de inserción.

This article presents the design and operation of the first prototype of a robot, designed to guide the insertion of screws in spinal fixation surgery. This type of surgery, usually done manually, could cause many injuries due to human error at the moment of inserting the screws into the patient’s vertebrae. Computed tomography can be used to avoid such errors, but the results are much better if a robot assists and indicates the surgeon the path for the insertion of the screw, according to the image scanner. This article shows how using a commercial low-cost robot can be implemented in a system that provides a practical solution to this problem. A software that allows you to define the start and the end positions of the screw to be introduced on the Dicom image of the patient, was implemented. With this information the system moves the robot which has a ring that will guide the surgeon in the final insertion. The results show a fairly accurate system, giving the surgeon a safe path of insertion.

[Usefulness of determining urinary trypsinogen-2 in diagnosis and prognosis of patients with acute pancreatitis]. / Valor diagnóstico y pronóstico de la determinación de tripsinógeno-2 urinario en pacientes con pancreatitis aguda.

BACKGROUND: To study the role of urinary trypsinogen-2 in diagnosing and early prognosis of patients with acute pancreatitis (AP) and the relationship to length of hospital stay and mortality. METHODS: Forty-two patients were included in the study. In all cases, blood cell count, serum chemistry, urine amylase and urine trypsinogen-2 were measured. A cut-off of 50 microg/L was established and, when positive, a second dilution was made (2000 microg/L). Other variables included were etiology, mean length of hospital stay, transfer to an ICU and death. RESULTS: Out of the 42 patients, 29 (69%) were men and 13 (31%) women. Average age was 61 years. The most frequent cause was biliary, followed by alcohol. Mean hospital stay was 8.38 days. Transferred to an ICU: 4 (9.5%) patients. Two of them and a third, who had not been transferred, died (7.14%). High serum amylase was found in 33 (78.57%) patients and high lipase in 36 (85.71%). Urinary trypsinogen-2 was positive in 34 patients (80.95%). Statistical association between urinary trypsinogen-2 and age (p=0.016; r=0.893), glucose (p=0.005; r=0.901), serum amylase (p=0.029; r=0.852), lipase (p=0.022; r=0.809) and hypoxemia (p=0.001; r=0.962) was found. Regarding hospital stay, there was statistical association with age (p=0.046; r=0.784) and metabolic acidosis (p=0.016; r=0.839). With respect to mortality there was statistical association with hypocalcemia (p=0.008; r=0.899) and metabolic acidosis (p=0.032; r=0.814). CONCLUSION: Testing urinary trypsinogen-2 in patients with AP is rapid and useful. Patients over the age of 65 with hypoxia, metabolic acidosis and hypocalcemia tend to present a prolonged average hospital stay and higher mortality.