The complexity of classifying ANCA-associated small-vessel vasculitis in actual clinical practice: data from a multicenter retrospective survey.

The different sets of criteria for diagnosis or classification of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) lead to numerous overlapping and reclassified diagnoses in clinical practice. We designed this study to assess the difficulties in classifying patients with AAV. As a secondary objective, different variables were tested to predict prognosis. We conducted a retrospective chart review in a Western Spain multicentre survey. A total of 115 adult patients diagnosed with AAV from 2002 to 2013 and followed for at least 3 years were included. They were classified according to (1) Chapel Hill Consensus Conference (CHCC), (2) European Medicines Agency algorithm and (3) French Vasculitis Study Group/European Vasculitis Society phenotypes. Fifty-three patients (46%) had neither distinctive histopathological data of a single AAV definition nor any surrogate markers for granulomatous inflammation and thus did not fulfill any diagnostic criteria. Ocular, ear, nose, throat, skin, and lung involvement were more frequent with proteinase 3 (PR3) antibodies, whereas peripheral neuropathy was more frequent with myeloperoxidase (MPO) antibodies. When the disease was severe at diagnosis, the HR for mortality was 10.44. When induction treatment was not given in accordance with the guidelines, the HR for mortality was 4.00. For maintenance treatment, the HR was 5.49 for mortality and 2.48 for relapse. AAV classification is difficult because many patients had neither specific clinical data nor distinctive histological features of a single CHCC definition. A structured clinical assessment of patient severity is the best tool to guide the management of AAV.

Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization.

INTRODUCTION: Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value. METHODS: We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices. RESULTS: BR or DR at admission were recommended in 37% (32-44) and 24% (19-30) of the patients respectively. In 81% (71-87) and 33% (21-45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92-98) had VL and 25% (19-32) UC. VL were not used in 10% (6-12), UC had no indications for insertion in 21% (11-35) and for maintenance in 31% (12-46) patients. Fifty-seven percent (49-64) of the patients were administered VTP and 69% (62-76) were prescribed SUP. Twenty-two percent (15-31) of patients with VTP and 52% (43-60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53-75) with BAF was prescribed in 38% (25-52) of them. An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results. CONCLUSION: These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.

Determinantes culturales de la salud. Opinión Novel / Cultural determinants of health. Novel opinion

Los determinantes de salud son propiedades basadas en el estilo de vida afectadas por amplias fuerzas sociales, económicas y políticas que influyen la calidad de la salud personal (1). Dentro de este grupo de propiedades se encuentran en un plano distal los determinantes culturales, los cuales son indispensables para el abordaje y entendimiento del proceso salud-enfermedad en una sociedad. A pesar de no existir una definición concreta sobre determinantes culturales, en el ejercicio para aproximarnos en la construcción de este, es conveniente primeramente definir el concepto de cultura, la cual, es entendida como conjunto de valores, costumbres, creencia y prácticas que constituyen la forma de vida de un grupo específico (2). Luego entonces, la cultura como determinante, son todas las formas y expresiones que caracterizan una población y determinan su estado de salud, tales como, etnicidad, el nivel educativo, género, religión, lengua, cosmovisión, arquetipos, creencias, costumbres y valores.

[Total laparoscopic mesorectal excision versus robot-assisted in the treatment of rectal cancer: a meta-analysis]. / Escisión mesorrectal total laparoscópica versus asistida por robot en el tratamiento del cáncer de recto: un metaanálisis.

A systematic literature review and meta-analysis was performed using the MEDLINE, EMBASE and COCHRANE LIBRARY data bases, and identifying clinical trials, published between the years 2005 to 2010, that compared the short term results of conventional laparoscopic total mesorectal excision (L-TME) and robot-assisted total mesorectal excision (RA-TME) in the treatment of non-complicated rectal cancer. Five trials with a total of 380 patients were selected, of whom 169 were subjected to RA-TME and 211 to L-TME. No significant differences were found, although RA-TME was associated with a lower conversion rate, a greater resection margin circumference, and higher number of isolated lymph nodes, as well as a lower overall rate of complications. There was no evidence that RA-TME had advantages that compensated for the longer duration of the surgery and the higher cost of the procedure. More randomised prospective studies and a greater number of patients are needed.