Hemispheric functional segregation facilitates target detection during sustained visuospatial attention.

Visuospatial attention is strongly lateralized, with the right hemisphere commonly exhibiting stronger activation and connectivity patterns than the left hemisphere during attentive processes. However, whether such asymmetry influences inter-hemispheric information transfer and behavioral performance is not known. Here we used a region of interest (ROI) and network-based approach to determine steady-state fMRI functional connectivity (FC) in the whole cerebral cortex during a leftward/rightward covert visuospatial attention task. We found that the global FC topology between either ROIs or networks was independent on the attended side. The side of attention significantly modulated FC strength between brain networks, with leftward attention primarily involving the connections of the right visual network with dorsal and ventral attention networks in both the left and right hemisphere. High hemispheric functional segregation significantly correlated with faster target detection response times (i.e., better performance). Our findings suggest that the dominance of the right hemisphere in visuospatial attention is associated with an hemispheric functional segregation that is beneficial for behavioral performance.

Cáncer de mama triple negativo, abortos a repetición e isquemia digital grave / Triple negative breast cancer, repeated abortions and severe digital ischemia

Resumen El presente caso corresponde a una mujer con antecedentes de tres abortos de menos de 10 semanas y cáncer de mama, que desarrolló isquemia digital grave luego del segundo ciclo de capecitabina. Se determinó la presencia de anticuerpos antifosfolipídicos positivos. Dado que las pacientes con síndrome antifosfolipídico obstétrico tienen incremento del riesgo de desarrollar neoplasia y que la isquemia digital grave puede ser la forma de presentación del síndrome antifosfolipídico en los pacientes con cáncer, se presenta el caso para remarcar el beneficio de pesquisar y realizar un diagnóstico temprano de estas características de la enfermedad.

Abstract The present case corresponds to a woman with history of three miscarrieges less than10 weeks and breast cancer, who develops severe digital ischemia after the second cycle of capecitabine. Positive antiphospholipid antibodies were determined. Patients with obstetric antiphospholipid syndrome have an increased risk of developing cancer, and severe digital ischemia could be an unusual form of presentation of the antiphospholipid syndrome in patients with cancer. This case is presented to highlight the benefit of researching and making an early diagnosis of these characteristics of the disease.

[Triple negative breast cancer, repeated abortions and severe digital ischemia]. / Cáncer de mama triple negativo, abortos a repetición e isquemia digital grave.

The present case corresponds to a woman with history of three miscarrieges less than10 weeks and breast cancer, who develops severe digital ischemia after the second cycle of capecitabine. Positive antiphospholipid antibodies were determined. Patients with obstetric antiphospholipid syndrome have an increased risk of developing cancer, and severe digital ischemia could be an unusual form of presentation of the antiphospholipid syndrome in patients with cancer. This case is presented to highlight the benefit of researching and making an early diagnosis of these characteristics of the disease.

El presente caso corresponde a una mujer con antecedentes de tres abortos de menos de 10 semanas y cáncer de mama, que desarrolló isquemia digital grave luego del segundo ciclo de capecitabina. Se determinó la presencia de anticuerpos antifosfolipídicos positivos. Dado que las pacientes con síndrome antifosfolipídico obstétrico tienen incremento del riesgo de desarrollar neoplasia y que la isquemia digital grave puede ser la forma de presentación del síndrome antifosfolipídico en los pacientes con cáncer, se presenta el caso para remarcar el beneficio de pesquisar y realizar un diagnóstico temprano de estas características de la enfermedad.

Rehabilitation of Severe to Profound Sensorineural Hearing Loss in Adults: Audiological Outcomes.

The aim of this article is to describe the audiological patterns of 71 adult patients presenting severe to profound sensorineural hearing loss, who were rehabilitated by cochlear implants (CIs) and hearing aids. This is a retrospective study in a university setting, where the clinical records of 71 adult patients were reviewed and processed. Speech intelligibility was evaluated at one aided ear (CI) or at both aided ears (double CI or a combination of CI and hearing aid [HA]). Patients with a bilateral CI or with a bimodal hearing setup (CI and HA) performed better than those with a single CI; data from the phonetic matrices test showed that there was a statistically significant difference among patients aided by a single CI versus binaural setup (double CI or CI + HA). In particular, patients aided by a bilateral CI, or by a CI and HA, showed an improvement in the functional results of the speech tests, compared to patients using a single CI. Binaural hearing (either with a bilateral CI or bimodal) allows an improvement in the functional results at the speech tests, compared to the use of a CI only.

Cortical laminar resting-state signal fluctuations scale with the hypercapnic blood oxygenation level-dependent response.

Calibrated functional magnetic resonance imaging can remove unwanted sources of signal variability in the blood oxygenation level-dependent (BOLD) response. This is achieved by scaling, using information from a perfusion-sensitive scan during a purely vascular challenge, typically induced by a gas manipulation or a breath-hold task. In this work, we seek for a validation of the use of the resting-state fluctuation amplitude (RSFA) as a scaling factor to remove vascular contributions from the BOLD response. Given the peculiarity of depth-dependent vascularization in gray matter, BOLD and vascular space occupancy (VASO) data were acquired at submillimeter resolution and averaged across cortical laminae. RSFA from the primary motor cortex was, thus, compared to the amplitude of hypercapnia-induced signal changes (tSDhc ) and with the M factor of the Davis model on a laminar level. High linear correlations were observed for RSFA and tSDhc ( R2 = 0.92 ± 0.06) and somewhat reduced for RSFA and M ( R2 = 0.62 ± 0.19). Laminar profiles of RSFA-normalized BOLD signal changes yielded good agreement with corresponding VASO profiles. Overall, this suggests that RSFA contains strong vascular components and is also modulated by baseline quantities contained in the M factor. We conclude that RSFA may replace the scaling factor tSDhc for normalizing the laminar BOLD response.

Techniques for blood volume fMRI with VASO: From low-resolution mapping towards sub-millimeter layer-dependent applications.

Quantitative cerebral blood volume (CBV) fMRI has the potential to overcome several specific limitations of BOLD fMRI. It provides direct physiological interpretability and promises superior localization specificity in applications of sub-millimeter resolution fMRI applications at ultra-high magnetic fields (7T and higher). Non-invasive CBV fMRI using VASO (vascular space occupancy), however, is inherently limited with respect to its data acquisition efficiency, restricting its imaging coverage and achievable spatial and temporal resolution. This limitation may be reduced with recent advanced acceleration and reconstruction strategies that allow two-dimensional acceleration, such as in simultaneous multi-slice (SMS) 2D-EPI or 3D-EPI in combination with CAIPIRINHA field-of-view shifting. In this study, we sought to determine the functional sensitivity and specificity of these readout strategies with VASO over a broad range of spatial resolutions; spanning from low spatial resolution (3mm) whole-cortex to sub-millimeter (0.75mm) slab-of-cortex (for cortical layer-dependent applications). In the thermal-noise-dominated regime of sub-millimeter resolutions, 3D-EPI-VASO provides higher temporal stability and sensitivity to detect changes in CBV compared to 2D-EPI-VASO. In this regime, 3D-EPI-VASO unveils task activation located in the cortical laminae with little contamination from surface veins, in contrast to the cortical surface weighting of GE-BOLD fMRI. In the physiological-noise-dominated regime of lower resolutions, however, 2D-SMS-VASO shows superior performance compared to 3D-EPI-VASO. Due to its superior sensitivity at a layer-dependent level, 3D-EPI VASO promises to play an important role in future neuroscientific applications of layer-dependent fMRI.

High-Resolution CBV-fMRI Allows Mapping of Laminar Activity and Connectivity of Cortical Input and Output in Human M1.

Layer-dependent fMRI allows measurements of information flow in cortical circuits, as afferent and efferent connections terminate in different cortical layers. However, it is unknown to what level human fMRI is specific and sensitive enough to reveal directional functional activity across layers. To answer this question, we developed acquisition and analysis methods for blood-oxygen-level-dependent (BOLD) and cerebral-blood-volume (CBV)-based laminar fMRI and used these to discriminate four different tasks in the human motor cortex (M1). In agreement with anatomical data from animal studies, we found evidence for somatosensory and premotor input in superficial layers of M1 and for cortico-spinal motor output in deep layers. Laminar resting-state fMRI showed directional functional connectivity of M1 with somatosensory and premotor areas. Our findings demonstrate that CBV-fMRI can be used to investigate cortical activity in humans with unprecedented detail, allowing investigations of information flow between brain regions and outperforming conventional BOLD results that are often buried under vascular biases.

Lamina-dependent calibrated BOLD response in human primary motor cortex.

Disentangling neural activity at different cortical depths during a functional task has recently generated growing interest, since this would allow to separate feedforward and feedback activity. The majority of layer-dependent studies have, so far, relied on gradient-recalled echo (GRE) blood-oxygenation-level dependent (BOLD) acquisitions, which are weighted towards the large draining veins at the cortical surface. The current study aims to obtain quantitative brain activity responses in the primary motor cortex on a laminar scale without the contamination due to accompanying secondary vascular effects. Evoked oxidative metabolism was evaluated using the Davis model, to investigate its applicability, advantages, and limits in lamina-dependent fMRI. Average values for the calibration parameter, M, and for changes in the cerebral metabolic rate of oxygen consumption (CMRO2) during a unilateral finger-tapping task were (11±2)% and (30±7)%, respectively, with distinct variation features across the cortical depth. The results presented here showed an uncoupling between BOLD-based functional magnetic resonance imaging (fMRI) and metabolic changes across cortical depth, while the tight coupling between CMRO2 and CBV was conserved across cortical layers. We conclude that the Davis model can help to obtain estimates of lamina-dependent metabolic changes without contamination from large draining veins, with high consistency and reproducibility across participants.

Complications of Neck Dissections in Papillary Thyroid Carcinoma: A Modified Procedure to Reduce Parathyroid Morbidity.

BACKGROUND/AIM: Hypoparathyroidism is the most significant morbidity after neck dissection for thyroid cancer. Addition of lateral neck dissection (ND) to central ND combined with total thyroidectomy (TT) increases the risk of postoperative hypoparathyroidism compared to TT plus central ND. The aim of this study was to verify if a modified procedure and different access to the neck for lateral ND may improve safety. PATIENTS AND METHODS: In 62 patients with papillary thyroid cancer (PTC) undergoing TT plus central and lateral ND between 2010 and 2013, lateral ND was performed as first step approaching the neck via extrathyroideal space. Calcium in serum and parathormone (PTH) were determined preoperatively, intraoperatively and during the follow-up. RESULTS: Twenty patients (32%) developed postoperative hypocalcemia. Calcium levels and PTH completely recovered for 58 out of 62 patients from 3 to 6 months after surgery. After a mean of 12 months' follow-up, only four patients (6.5%) had developed permanent hypoparathyroidism. The incidence of parathyroid complication after TT plus central ND and lateral ND did not differ from postoperative hypoparathyroidim after TT plus central ND. CONCLUSION: The presented surgical procedure may provide a better outcome in terms of parathyroid morbidity.

Functional cerebral blood volume mapping with simultaneous multi-slice acquisition.

The aim of this study is to overcome the current limits of brain coverage available with multi-slice echo planar imaging (EPI) for vascular space occupancy (VASO) mapping. By incorporating simultaneous multi-slice (SMS) EPI image acquisition into slice-saturation slab-inversion VASO (SS-SI VASO), many more slices can be acquired for non-invasive functional measurements of blood volume responses. Blood-volume-weighted VASO and gradient echo blood oxygenation level-dependent (GE-BOLD) data were acquired in humans at 7T with a 32-channel head coil. SMS-VASO was applied in three scenarios: A) high-resolution acquisition of spatially distant brain areas in the visuo-motor network (V1/V5/M1/S1); B) high-resolution acquisition of an imaging slab covering the entire M1/S1 hand regions; and C) low-resolution acquisition with near whole-brain coverage. The results show that the SMS-VASO sequence provided images enabling robust detection of blood volume changes in up to 20 slices with signal readout durations shorter than 150ms. High-resolution application of SMS-VASO revealed improved specificity of VASO to GM tissue without contamination from large draining veins compared to GE-BOLD in the visual cortex and in the sensory-motor cortex. It is concluded that VASO fMRI with SMS-EPI allows obtaining a reasonable three-dimensional coverage not achievable with standard VASO during the short time period when blood magnetization is approximately nulled. Due to the increased brain coverage and better spatial specificity to GM tissue of VASO compared to GE-BOLD signal, the proposed method may play an important role in high-resolution human fMRI at 7T.

Oncologic outcome of hypopharyngeal carcinoma treated with different modalities at 2 different university hospitals.

BACKGROUND: The hypopharynx is the site with the worst prognosis among head and neck squamous cell carcinomas (SCCs). The purpose of this study was to evaluate the oncologic outcomes of hypopharyngeal SCCs to identify the major clinical predictive factors and to compare the different primary therapeutic modalities. METHODS: The medical records of 123 consecutive patients diagnosed with primary resectable hypopharyngeal SCC were reviewed. The correlations of oncologic endpoints with tumor parameters and primary treatment were evaluated. RESULTS: The overall survival (OS) rate was 76% and the disease-specific survival (DSS) rate was 80% at 3 years in the entire group. Sex and T and N classifications significantly influenced survival in both univariate and multivariate analyses. Seventy-four percent of our patients underwent both surgery and radiotherapy (RT), and the temporal sequence of the 2 modalities did not affect prognosis. CONCLUSION: The primary treatment modality in patients with resectable hypopharyngeal SCC did not affect prognosis in univariate and multivariate analyses for any stage considered.

Suspected natural lysosomal storage disease from ingestion of pink morning glory (Ipomoea carnea) in goats in northern Argentina.

This study describes an occurrence of pink morning glory (Ipomoea carnea) intoxication in goats in northern Argentina. The clinical signs displayed by the affected animals were ataxia, lethargy, emaciation, hypertonia of the neck muscles, spastic paresis in the hind legs, abnormal postural reactions and death. The clinico-pathologic examination revealed that the affected animals were anemic and their serum level of aspartate aminotransferase was significantly increased. Cytoplasmic vacuolation in the Purkinje cells and pancreatic acinar cells was observed by histological examination. The neuronal lectin binding pattern showed a strong positive reaction to WGA (Triticum vulgaris), sWGA (succinylated T. vulgaris) and LCA (Lens culinaris). Although I. carnea is common in tropical regions, this is the first report of spontaneous poisoning in goats in Argentina.

Cortical lamina-dependent blood volume changes in human brain at 7 T.

Cortical layer-dependent high (sub-millimeter) resolution functional magnetic resonance imaging (fMRI) in human or animal brain can be used to address questions regarding the functioning of cortical circuits, such as the effect of different afferent and efferent connectivities on activity in specific cortical layers. The sensitivity of gradient echo (GE) blood oxygenation level-dependent (BOLD) responses to large draining veins reduces its local specificity and can render the interpretation of the underlying laminar neural activity impossible. The application of the more spatially specific cerebral blood volume (CBV)-based fMRI in humans has been hindered by the low sensitivity of the noninvasive modalities available. Here, a vascular space occupancy (VASO) variant, adapted for use at high field, is further optimized to capture layer-dependent activity changes in human motor cortex at sub-millimeter resolution. Acquired activation maps and cortical profiles show that the VASO signal peaks in gray matter at 0.8-1.6mm depth, and deeper compared to the superficial and vein-dominated GE-BOLD responses. Validation of the VASO signal change versus well-established iron-oxide contrast agent based fMRI methods in animals showed the same cortical profiles of CBV change, after normalization for lamina-dependent baseline CBV. In order to evaluate its potential of revealing small lamina-dependent signal differences due to modulations of the input-output characteristics, layer-dependent VASO responses were investigated in the ipsilateral hemisphere during unilateral finger tapping. Positive activation in ipsilateral primary motor cortex and negative activation in ipsilateral primary sensory cortex were observed. This feature is only visible in high-resolution fMRI where opposing sides of a sulcus can be investigated independently because of a lack of partial volume effects. Based on the results presented here, we conclude that VASO offers good reproducibility, high sensitivity and lower sensitivity than GE-BOLD to changes in larger vessels, making it a valuable tool for layer-dependent fMRI studies in humans.

Experimental poisoning of goats by Ipomoea carnea subsp. fistulosa in Argentina: a clinic and pathological correlation with special consideration on the central nervous system / Intoxicação experimental por Ipomoea carnea subsp. fistulosa em caprinos da Argentina: correlação clínico-patológica, com especial atenção ao sistema nervoso central

Ipomoea carnea subsp. fistulosa, aguapei or mandiyura, is responsible for lysosomal storage in goats. The shrub contains several alkaloids, mainly swansonine which inhibits lysosomal α-mannosidase and Golgi mannosidase II. Poisoning occurs by inhibition of these hydrolases. There is neuronal vacuolation, endocrine dysfunction, cardiovascular and gastrointestinal injury, and immune disorders. Clinical signs and pathology of the experimental poisoning of goats by Ipomoea carnea in Argentina are here described. Five goats received fresh leaves and stems of Ipomoea. At the beginning, the goats did not consume the plant, but later, it was preferred over any other forage. High dose induced rapid intoxication, whereas with low doses, the course of the toxicosis was more protracted. The goats were euthanized when they were recumbent. Cerebrum, cerebellum, medulla oblongata, pons and colliculi, were routinely processed for histology. In nine days, the following clinical signs developed: abnormal fascies, dilated nostrils and abnormal postures of the head, cephalic tremors and nystagmus, difficulty in standing. Subsequently, the goats had a tendency to fall, always to the left, with spastic convulsions. There was lack in coordination of voluntary movements due to Purkinje and deep nuclei neurons damage. The cochlear reflex originated hyperreflexia, abnormal posture, head movements and tremors. The withdrawal reflex produced flexor muscles hypersensitivity at the four legs, later depression and stupor. Abnormal responses to sounds were related to collicular lesions. Thalamic damage altered the withdrawal reflex, showing incomplete reaction. The observed cervical hair bristling was attributed to a thalamic regulated nociceptive response. Depression may be associated with agonists of lysergic acid contained in Ipomoea. These clinical signs were correlated with lesions in different parts of the CNS.

Ipomoea carnea subsp. fistulosa, aguapeí ou mandiyura, causa uma doença de depósito lisossomal em caprinos. A planta contém vários alcalóides, principalmente swansonine, que inibe uma α-mannosidase lisossomal e uma mannosidase II do Golgi. A intoxicação ocorre pela inibição dessas hidrolases. Há vacuolização neuronal, disfunção endócrina, lesões cardiovasculares e gastrointestinais e distúrbios imunológicos. No presente trabalho é descrita a intoxicação experimental por Ipomoea carnea subsp. fistulosa em caprinos da Argentina. Cinco cabras receberam folhas frescas e ramos de Ipomoea. No começo eles não consumiram a planta, mas depois ela foi preferida a qualquer outras forrageiras. Altas doses induziram uma intoxicação rápida, enquanto que com doses baixas demora mais tempo. As cabras foram sacrificadas quando ficavam em decúbito. Cérebro, cerebelo, medula oblonga, ponte e colículos foram processados rotineiramente para histologia. Aos nove dias, encontramos: fascie anormal, narinas dilatadas, posturas anormais da cabeça, tremores cefálicos e nistagmo, dificuldade para permanecer na estação. Posteriormente, presentearam a tendência de queda, sempre à esquerda, com convulsões espásticas. Os neurônios de Purkinje e os os núcleos profundos foram danificados. Como conseqüência, emergiu a falta de coordenação de movimentos voluntários. A hiper-reflexo coclear originou postura anormal, movimentos de cabeça e tremores. A retirada produz reflexos hipersensibilidade nos flexores dos quatro membros, depois depressão e letargia. As respostas anormais estão ligadas a lesões do colículo. Injurias no tálamo alteram o reflexo de retirada, mostrando uma reação incompleta. Os pelos eriçados da região cervical podem representar uma resposta nociceptiva também regulada pelo tálamo. A depressão pode estar associada com agonistas do ácido lisérgico presentes na Ipomoea. Esses sintomas estão relacionados com lesões em diferentes partes do SNC.

The Italian Registry of Therapeutic Apheresis: granulocyte-monocyte apheresis in the treatment of inflammatory bowel disease. A multicentric study.

Leukocytes are thought to play an important role in the pathogenesis of inflammatory bowel diseases; granulocyte-monocyte adsorptive (GMA) apheresis, an extracorporeal technique aimed at removing activated circulating leukocytes from the blood, may represent a safe and effective therapeutic tool in these patients. The Italian Registry of Therapeutic Apheresis performed an observational, multicentric study involving 24 Gastroenterology Units. In this study, laboratory data and clinical outcomes of 230 patients (148 males, mean age 43.5 years) affected with ulcerative colitis (UC, n = 194) or Crohn's disease (CD, n = 36) who underwent one or more cycles of GMA were analyzed. Each cycle consisted of five GMA treatments. The patients were followed up for a mean of 8.7 (min. 3 to max. 12) months. At 3 months, positive outcome was achieved in 77.7% of UC patients (72.0% remission, 5.7% clinical response) and 61.3% of CD patients (54.8% remission, 6.5% clinical response). The cumulative proportion of positive outcome at 12 months was 87.1% for UC patients (83.7% remission, 3.4% clinical response) and 77.4% for CD patients (74.2% remission, 3.2% clinical response). No single clinical or laboratory parameter among those analyzed (age, sex, disease characteristics, history of smoking, medication history, baseline values of clinical activity index (CAI)/Crohn's disease activity index (CDAI), hemoglobin, white blood cells count, and erythrocyte sedimentation rate) was independently associated with clinical outcome. The procedure was well tolerated with no significant adverse effects registered.

Current trends in paediatric tracheostomies.

OBJECTIVE: In the 1970s, the most common indication for tracheostomy in children was acute inflammatory airway obstruction. Modern neonatal intensive care units have turned long-term intubation into an alternative to tracheostomy. Long-term intubation itself has become the most important indication for tracheostomy combined with subglottic stenosis. METHODS: Retrospective analysis in a tertiary referral center. A total of 38 patients who underwent tracheostomy for respiratory failure and upper airway obstruction from 1 November 1998 to 30 November 2004. RESULTS: Total complication rate was 42.1%. In children under 1 year of age the complication rate was 47.4%, in children over 1 year the complication rate was 26.3%. Decannulation was attempted in 12 patients with a cannulation time of 22 months. CONCLUSIONS: Long-term intubation and its sequelae have now become one of the most important indication for tracheostomy. The change of indication has also entailed a decrease of the average age of children who require tracheostomy. A longer period before decannulation and a lower average age have changed the complication rate of tracheostomy in paediatric patients.

Revisited anatomy of the recurrent laryngeal nerves.

BACKGROUND: The most frequent postthyroidectomy complication is recurrent laryngeal nerve (RLN) damage with subsequent vocal cord palsy. METHODS: We have undertaken an intraoperative study aimed to determine the course, distribution, and RLN's anatomical relationships with adjacent structures. Only its identification and its careful exposure allow prevention of iatrogenic injuries. RESULTS: The RLN was always routinely exposed and identified in 1,543 thyroidectomies. All patients underwent laryngoscopic evaluation before surgery and at the time of discharge. A total of 2,626 RLN were observed. The number of nerves exposed to risk was 673 (25.6%). In the whole series, of 2626 nerves controlled, there were 11 (0.4%) permanent palsies. CONCLUSIONS: Our study confirms that damage to the RLN or to one of its branches may be avoided only by identification and careful exposure of the nerve itself. An experienced surgeon with good knowledge of the anatomy of the RLN and its anatomical variations is required for uncomplicated treatment of thyroid disease.

Control y prevención secundaria para personas con diabetes: impacto de la implementación de un programa de atención (PROPAT) / Control and secondary prevention for people with diabetes: impact of the implementation of a healthcare program (PROPAT)

Evaluar el efecto de un programa de atención para personas con diabetes (PROPAT) implementado en el Instituto de Obra Médico Asistencial (IOMA) de la Provincia de Buenos Aires sobre la prevención secundaria, la calidad y los costos de atención. Material y métodos: Afiliados con diabetes de 4 ciudades de la Provincia de Buenos Aires se incorporaron por libre elección al (PROPAT), programa que incluyó innovaciones al actual sistema de atención de estos pacientes, tales como la provisión de estándares de atención a los prestadores, prescripción de dieta por la nutricionista; interconsulta anual con otros especialistas, educación del paciente, y otras estrategias de prevención. El programa se evaluó a través de indicadores de calidad de atención obtenidos de múltiples fuentes de información. Los datos de 297 pacientes enrolados en el PROPAT (basal y al año de su ingreso al Programa) se evaluaron y compararon con los de 594 pacientes de otras 4 ciudades donde estaban implementados programas convencionales de atención. Resultados: Se observó un aumento significativo en la realización de prácticas diagnósticas y de control tales como control de los pies, de la HbA1c y microalbuminuria, automonitoreo glucémico y glucosúrico, consulta anual con el cardiólogo y el oftalmólogo, con la nutricionista, asistencia a cursos de educación e interconsulta con el diabetólogo (p<0.001). También se observó una mejoría significativa de diversos parámetros clínicos y bioquímicos, con una disminución del 43 por ciento de las complicaciones agudas. La mejoría en los niveles de Hba1c permite estimar una disminución significativa del desarrollo de complicaciones crónicas a mediano plazo. Disminuyó también la frecuencia y duración de las hospitalizaciones anuales (p=0.02). Estos cambios se acompañaron de una reducción del 28 por ciento del costo anual de tratamiento de cada paciente. Conclusiones: Nuestros resultados muestran que la implementación del PROPAT mejoró la calidad de atención de las personas con diabetes, previno el desarrollo inmediato de complicaciones agudas y el desarrollo a mediano plazo de las complicaciones crónicas, con una disminución concomitante del costo anual de atención

Evaluación y costos del proceso de atención de pacientes diabéticos / Evaluation and cost of the health care process of diabetic patients

El objetivo del estudio fue evaluar la calidad y los costos de la atención brindada a personas con diabetes en La Plata, Argentina, a través de la obra social para empleados del sector público de la Provincia de Buenos Aires (IOMA - Instituto de Obra Médico Asistencial de la Provincia de Buenos Aires). Para ello, se entrevistaron 1.590 afiliados con diabetes, y se analizaron los datos obtenidos mediante el análisis univariado y de regresión logística múltiple. Los pacientes tratados sin insulina (48%) fueron significativamente mayores, y presentaron obesidad, hipertensión y macroangiopatía con más frecuencia que los tratados con insulina. La tasa de internación fue significativamente más alta en los pacientes tratados con insulina y comparable en las personas sin complicaciones o que sólo presentaron microangiopatía, pero aumentó significativamente en las personas con macroangiopatía. Muchas de las prácticas recomendadas en normas internacionales no se realizaron durante el año previo: examen de los pies (20-30%), derivación al oftalmólogo (21-29%), y determinación de HbA1c (60-78%). Contrariamente, la tasa de uso de pruebas diagnósticas y el número de visitas al médico de cabecera fue alto, inclusive en pacientes sin complicaciones, resultando en un costo estimado de atención 22.7% superior al esperado si los exámenes y prácticas se hubieran realizado siguiendo las recomendaciones de las normas internacionales. En conclusión, la atención actual de la diabetes es ineficaz y costosa. La implementación de normas de atención basadas en consensos nacionales e internacionales resultaría en una distribución más eficaz de los recursos, mejorando la calidad de atención de las personas con diabetes y su calidad de vida.

Diseño e implementación de un programa de prevención, atención y tratamiento de personas con diabetes en una entidad financiadora de servicios de salud / Design and implementation of a program to prevent, assist and treat people with diabetes in health care services

La diabetes mellitus (DM) es una enfermedad metabólica crónica, generadora de complicaciones que causan discapacidad, muerte prematura y altos costos de atención y socioeconómicos. Para su diagnóstico, control y tratamiento, se requiere un equipo interdisciplinario, técnicas bioquímicas, otras técnicas modernas no invasivas y la implementación de pautas de atención tendientes a mejorar la calidad de vida y promover la prevención de las complicaciones. Todo esto señala la necesidad de la sistematización de un Programa de atención que permita optimizar el acceso y el uso eficaz y eficiente de los recursos disponibles, para modificar el curso natural y disminuir sus costos socioeconómicos. Siendo la DM una de las enfermedades trazadoras, las estrategias utilizadas para mejorar la calidad de su control y tratamiento pueden ser transferidas a otras enfermedades crónicas. El Programa propuesto contempla innovaciones en el actual Sistema de Atención de las personas con DM: incorporación de la nutricionista al equipo interdisciplinario, jerarquización de la consulta médica, interconsulta anual con especialistas y educación de los pacientes e incorporación de estrategias de prevención. También incluye un sistema de monitoreo continuo de la evolucición de las personas con DM y de los resultados del Programa a través de un conjunto de indicadores de uso y calidad de atención y su evaluación por un comité intersectorial