Quality of Life After Ministernotomy Versus Full Sternotomy Aortic Valve Replacement.

Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomized trials. The QUALITY-AVR trial is a single-blind, single-center, independent, randomized clinical trial comparing ministernotomy to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients were randomized in a 1:1 computational fashion. The primary endpoint was a difference between intervention groups of ≥0.10 points in change from baseline quality of life Questionnaire EuroQOL-index, measured at 1, 6, or 12 months. Secondary endpoints were differences in change from other baseline EuroQOL-index utilities, cardiac surgery-specific satisfaction questionnaire (SATISCORE), a combined safety endpoint of 4 major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events, and acute renal failure), bleeding through drains within the first 24 hours, intubation time, and other minor endpoints. Clinical follow-up was scheduled at baseline, 1, 6, and 12 months after randomization. Change from baseline mean difference EQ-5D-index was +0.20 points (95% confidence interval 0.10-0.30, P < 0.001) and median difference +0.14 (95% confidence interval 0.06-0.22, P < 0.001), favoring the ministernotomy group at 1 month. Patient satisfaction was also better at 1 month (Satiscore 83 ± 9 vs 77 ± 13 points; P = 0.010). The ministernotomy group had significantly less bleeding in the first 24 hours (299 ± 140 vs 509 ± 251 mL, P = 0.001). Ministernotomy provides a faster recovery with improved quality of life and satisfaction at 1 month compared to full sternotomy.

Quality of life, satisfaction and outcomes after ministernotomy versus full sternotomy isolated aortic valve replacement (QUALITY-AVR): study protocol for a randomised controlled trial.

BACKGROUND: During the last decade, the use of ministernotomy in cardiac surgery has increased. Quality of life and patient satisfaction after ministernotomy have never been compared to conventional full sternotomy in randomised trials. The aim of the study is to determine if this minimally invasive approach improves quality of life, satisfaction and clinical morbimortality outcomes. METHODS/DESIGN: The QUALITY-AVR trial is a single-blind, single-centre, independent, and pragmatic randomised clinical trial comparing ministernotomy ("J" shaped upper hemisternotomy toward right 4th intercostal space) to full sternotomy in patients with isolated severe aortic stenosis scheduled for elective aortic valve replacement. One hundred patients will be randomised in a 1:1 computational fashion. Sample size was determined for the primary end point with alpha error of 0.05 and with power of 90% in detecting differences between intervention groups of ≥ 0.10 points in change from baseline quality of life Questionnaire EuroQOL-index (EQ-5D-5 L®), measured at 1, 6 or 12 months. Secondary endpoints are: the differences in change from other baseline EQ-5D-5 L® utilities (visual analogue scale, Health Index and Severity Index), cardiac surgery specific satisfaction questionnaire (SATISCORE®), a combined safety endpoint of four major adverse complications at 1 month (all-cause mortality, acute myocardial infarction, neurologic events and acute renal failure), bleeding through drains within the first 24 h, intubation time, postoperative hospital and intensive care unit length of stay, transfusion needs during the first 72 h and 1-year survival rates. Clinical follow up is scheduled at baseline, 1, 6, and 12 months after randomization. All clinical outcomes are recorded following the Valve Academic Research Consortium 2 criteria. DISCUSSION: The QUALITY-AVR trial aims to test the hypothesis that ministernotomy improves quality of life, satisfaction and clinical outcomes in patients referred for isolated aortic valve replacement. Statistically significant differences favouring ministernotomy could modify the surgical "gold standard" for aortic stenosis surgery, and subsequently the need to change the control group in transcatheter aortic valve implantation trials. Recruitment started on 18 March 2016. In November 2017, 75 patients were enrolled. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02726087 . Registered on 13 March 2016.

Increased blood levels of transforming growth factor ß in patients with aortic dilatation.

OBJECTIVES: Recent studies have shown that patients with syndromic thoracic aortic aneurysm, particularly patients with bicuspid aortic valve, have increased blood levels of transforming growth factor ß1 (TGF-ß1), indicating this molecule as a prognostic biomarker. However, it is not known whether TGF-ß1 is also elevated in the blood of patients with tricuspid aortic valve and aortic dilatation. METHODS: We analysed the plasma levels of TGF-ß1 in 52 patients with tricuspid or bicuspid aortic valve and with normal or dilated ascending aorta who underwent cardiac surgery in our hospital. RESULTS: TGF-ß1 blood level was significantly increased two-fold in patients with tricuspid aortic valve and dilated aorta compared to patients with tricuspid aortic valve and normal aorta. CONCLUSIONS: Our results suggest that TGF-ß1 blood levels may serve as a prognostic biomarker for patients with syndromic and non-syndromic thoracic aortic aneurysm. Further studies with larger cohorts of patients should be performed to confirm these results.

Descripción e identificación microscópica de ejemplares del género Lactarius de las secciones Uvidus y Zonarii en Guatemala / Microscopic description and identification of specimens of the genus Lactarius of the sections Uvidus and Zonarii in Guatemala

El género Lactarius (Basidiomicetes) se encuentra distribuido a nivel mundial y se caracteriza por presentar basidiomas coloridos que exudan látex. En este trabajo se estudiaron, con la finalidad de identificar la especie a la que pertenecen, 28 ejemplares de Lactarius adscritos a las secciones Uvidi y Zonarii, recolectados en Guatemala y que están depositados en la Micoteca "Rubén Mayorga Peralta" MICG, de la Facultad de Ciencias Químicas y Farmacia, de la Universidad de San Carlos de Guatemala. Se analizaron las esporas, crestas y el índice Q (relación largo/ancho), basidios, esterigmas, pleurocistidios, queilocistidios y estructura del pileipellis. También se analizaron características cualitativas como la reacción de las microestructuras al reactivo de Melzer y la presencia de incrustaciones en hifas. Se encontró que las microestructuras de 6 ejemplares analizados coincidieron en forma y dimensión con las especies Lactarius mexicanus, L. psammicola, L. argillaceofolius y L. chrysorheus, y 23 fueron afines a L. uvidus y L. montanus. Este trabajo confirmó la presencia en Guatemala de algunas especies reportadas en Norteamérica como L. montanus y L. mexicanus o L. psammicola informado sólo para Costa Rica

The genus Lactarius (Basidiomycetes) is distributed worldwide and is characterized by colorful basidiomata, which exude latex. On this study were analyzed, with the purpose of identifying the species where they belong. 28 dried mushroom samples of Lactarius, attached to Uvidus and Zonarii Sections, collected in Guatemala and placed at the Micoteca "Rubén Mayorga Perlata"-MICG- (herbarium) of the Faculty of Chemistry and Pharmacy, University of San Carlos of Guatemala. Spores, their crests and Q index were analyzed (length / width ratio). It also was analized the size of basidia, sterigmata, pleurocystidia, cheilocystidia, and pilleipelis structure; as well were analyzed qualitative characteristics such as microstructures reaction of Melzer's reagent and presence incrustations in hyphae. It was found that the microstructures of six samples match in shape and dimensions with Lactarius mexicanus, L. psammicola, L. chrysorheus. 23 are related to L. uvidus. This study confirms the presence of species In Guatemala which were only reported in North America such as L. montanus, L. mexicanus or separately reported in Costa Rica as L. psammicola

Endocarditis in patients with ascending aortic prosthetic graft: a case series from a national multicentre registry.

OBJECTIVES: Endocarditis in patients with ascending aortic prosthetic graft (AAPG) is a life-threatening complication. The purpose of this study was to examine the clinical presentation and prognosis of patients with AAPG endocarditis included in a large prospective infectious endocarditis multicentre study. METHODS: From January 2008 to April 2015, 3200 consecutive patients with infectious endocarditis according to the modified Duke criteria, were prospectively included in the 'Spanish Collaboration on Endocarditis Registry (GAMES)' registry. Twenty-seven definite episodes of endocarditis (0.8%) occurred in patients with AAPG. RESULTS: During the study period, 27 cases of endocarditis were detected in patients with AAPG. The median age of patients was 61 years [interquartile range (IQR) 51-68 years] and 23 (85.2%) patients were male. The median time from AAPG surgery to the episode of AAPG infection was 24 months (IQR 6-108 months). The most frequently isolated micro-organisms were coagulase-negative staphylococci and S. aureus (11 patients, 40.7%). Four patients (14.8%) underwent medical treatment, whereas surgery was performed in 21 (77.7%). Two patients (7.4%) died before surgery could be performed. The median hospital stay prior to surgery was 7 days (IQR 4-21 days). Surgery consisted of replacing previous grafts with a composite aortic graft (10 cases) or aortic homograft (2 patients), and removal of a large vegetation attached to the valve of a composite tube (1 case). Nine patients had an infected aortic valve prosthesis without evidence of involvement of the AAPG. Isolated redo-aortic valve replacement was performed in 8 (88.9%) of these patients. Reinfection occurring during 1 year of follow-up was not detected in any patient. Two patients (7.4%) died while awaiting surgery and 6 did so after surgery (22.2%). A New York Heart Association (NYHA) Class IV was associated with mortality in patients undergoing surgery (P < 0.019). CONCLUSIONS: Most cases of endocarditis in patients with AAPG occur late after initial surgery. Mortality rate of patients with AAPG endocarditis who undergo surgery is acceptable. NYHA Class IV before surgery is associated with an increased postoperative mortality.

Válvula aórtica bicúspide: resultados a largo plazo de la cirugía reparadora / Long-term Results with Reconstructiva Surgery of the Bicuspid Aortic Valve

Introducción: La válvula aórtica bicúspide es la anomalía congénita cardíaca más frecuente. En pacientes con requerimienro de cirugía, el tratamiento tradicional ha sido la sustitución valvular. La introducción del concepto de reparación de la válvula aórtica bicúspide ha llevado a nuestro grupo a reproducir las técnicas de reparación, las cuales se han estandarizado y aplicado de manera homogénea en nuestras instituciones. Objetivos: Revisar la experiencia conjunta de tres centros, con la presentación de los resultados a mediano y a largo plazos de la reparación valvular. Material y métodos: Entre octubre de 1995 y febrero de 2013 se intervinieron 666 pacientes con válvulas bicúspides e insuficiencia aórtica y/o aneurisma de la aorta. De ellos, 254 presentaban insuficiencia aórtica aislada y 412, aneurisma o disección. Se reconstruyó la válvula en todos los pacientes (en 254 como procedimiento aislado, en 281 "remodelación de la raíz", en 129 remodelación de la unión sinotubular y en 2 "reimplantación"). Resultados: La mortalidad fue de 3/666 (0,5%): 1/254 (0,4%) tras reparación valvular aislada y 2/410 (0,5%) tras reparación más reemplazo de la aorta. En pacientes con cirugía asociada (coronaria, reparación mitral/tricúspide) fue de 1/77 (1,3%). Durante el seguimiento murieron 12 pacientes (supervivencia a los 10 años: 95%). Las libertades de reoperación y de sustitución valvular a los 10 y 15 años fueron del 80% y 77% y del 86% y 83%, respectivamente. La libertad de reoperación a los 10 años fue superior en el reemplazo de la raíz (86%) o la aorta tubular (84%) en comparación con la reparación aislada (74%; p = 0,005). La libertad de cualquier complicación relacionada con la válvula fue del 80% y 77% a los 10 y 15 años, respectivamente, y fue mejor para reparación incluyendo "remodelación de la raíz" (87% y 82%) que para reparación aislada (77% y 77%; p = 0,04). Conclusiones: La reparación de la válvula aórtica bicúspide es un procedimiento seguro y duradero, con una incidencia baja de "complicaciones relacionadas con la válvula" a mediano y a largo plazos.

Introduction: Bicuspid aortic valve is the most common congenital heart disease. Traditionally, aortic valve replacement has been the approach for patients requiring surgery. After introduction of the bicuspid aortic valve repair concept, our group began reproducing these techniques, which have been standardized and homogeneously applied at our institutions. Objectives: The aim of this study was to review the conjoint experience of three centers and show the mid- and long-term results of bicuspid aortic valve repair. Methods: Between October 1995 and February 2013, 666 patients with bicuspid aortic valve underwent surgery for aortic regurgitation and/or aortic aneurysm. Isolated aortic regurgitation was present in 254 patients, and 412 had aortic aneurysm or dissection. The valve was reconstructed in all the patients (isolated valve repair in 254, "remodelling of the aortic root" in 281, remodelling of the sinotubular junction in 129 and "reimplantation" technique in 2). Results: Mortality was 3/666 (0.5%): 1/254 (0.4%) after isolated valve repair and 2/410 (0.5%) after valve repair plus aortic replacement. In patients with combined procedures (coronary revascularization or mitral/tricuspid valve repair), mortality was 1/77 (1.3%). During follow-up, 12 patients died (10-year survival: 95%). Freedom from reoperation and from aortic valve replacement at 10 and 15 years were 80% and 77%, and 86% and 83%, respectively Freedom from reoperation at 10 years was higher with aortic root (86%) or tubular aorta (84%) replacement, compared with isolated valve repair (74%; p = 0.005). Freedom from any valve-related complication was 80% and 77% at 10 and 15 years, respectively, and was better for valve repair including "remodelling of the aortic root" (87% and 82%) than for isolated repair (77% and 77%; p = 0.04). Conclusions: Bicuspid aortic valve repair is a safe, long-lasting procedure, with a low incidence of mid- and long-term "valve-related complications".

GATA5 and endothelial nitric oxide synthase expression in the ascending aorta is related to aortic size and valve morphology.

BACKGROUND: The pathogenesis of aortic dilatation in patients with congenital aortic valve anomalies is poorly understood. Recent studies suggest that alterations of gene expression may be related to ascending aortic aneurysm formation in these patients. Knockout of endothelial nitric oxide synthase (eNOS) and GATA5 is associated with bicuspid aortic valves in mice. To study the role of eNOS and GATA5 in human congenital aortic valve disease and aortic dilatation, we investigated their gene expression in aortic tissue from patients with unicuspid, bicuspid, and tricuspid aortic valves. METHODS: Samples from 84 patients (33 tricuspid, 32 bicuspid, and 19 unicuspid) were harvested intraoperatively from the ascending aorta. GATA5 and eNOS expression was determined by real-time polymerase chain reaction. RESULTS: GATA5 and eNOS expression in the aortic wall from patients with unicuspid aortic valves (GATA5: mean [M], 2.14; standard deviation [SD], 1.72; eNOS: M, 3.40; SD, 3.83) was significantly higher than in tricuspid aortic valves (GATA5: M, 1.12; SD, 0.80; eNOS: M, 1.00; SD, 0.74; each p < 0.05). Patients with bicuspid aortic valves (GATA5: M, 1.29, SD, 1.33; eNOS: M, 1.66; SD, 1.31) had a significantly higher eNOS expression than patients with tricuspid aortic valves (p < 0.05). The expression levels of eNOS and GATA5 correlated positively with each other and negatively with the ascending aortic diameter. CONCLUSIONS: Our data suggest that GATA5, possibly through upregulation of eNOS, plays a role in the development of aortic dilatation in patients with unicuspid and bicuspid aortic valves. The differential gene expression in patients with unicuspid compared with bicuspid aortic valves suggests that the pathogenesis of both aortic valve anomalies may be different.

A multicentre Spanish study for multivariate prediction of perioperative in-hospital cerebrovascular accident after coronary bypass surgery: the PACK2 score.

OBJECTIVES: To develop a multivariate predictive risk score of perioperative in-hospital stroke after coronary artery bypass grafting (CABG) surgery. METHOD: A total of 26 347 patients were enrolled from 21 Spanish hospital databases. Logistic regression analysis was used to predict the risk of perioperative stroke (ictus or transient ischaemic attack). The predictive scale was developed from a training set of data and validated by an independent test set, both selected randomly. The assessment of the accuracy of prediction was related to the area under the ROC curve. The variables considered were: preoperative (age, gender, diabetes mellitus, arterial hypertension, previous stroke, cardiac failure and/or left ventricular ejection fraction<40%, non-elective priority of surgery, extracardiac arteriopathy, chronic kidney failure and/or creatininemia≥2 mg/dl and atrial fibrillation) and intraoperative (on/off-pump). RESULTS: Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (priority; OR=2.32), vascular disease (arteriopathy; OR=1.37), cardiac failure (cardiac; OR=3.64) and chronic kidney failure (kidney; OR=6.78) were found to be independent risk factors for perioperative stroke in uni- and multivariate models in the training set of data; P<0.0001; AUC=0.77, 95% CI 0.73-0.82. The PACK2 stroke CABG score was established with 1 point for each item, except for chronic kidney failure with 2 points (range 0-5 points); AUC=0.76, 95% CI 0.72-0.80. In patients with PACK2 score≥2 points, off-pump reduced perioperative stoke incidence by 2.3% when compared with on-pump CABG. CONCLUSIONS: PACK2 risk scale shows good predictive accuracy in the data analysed and could be useful in clinical practice for decision making and patient selection.

Off-pump surgery in preventing perioperative stroke after coronary artery bypass grafting: a retrospective multicentre study.

OBJECTIVES: To determine the effect of the off-pump technique in preventing stroke development during the early perioperative period after coronary artery bypass graft surgery (CABG). METHODS: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish cardiac-surgery centres. Baseline variables related to perioperative stroke risk were recorded in the preoperative (age, gender, diabetes mellitus, arterial hypertension, prior stroke, cardiac failure: preoperative New York Heart Association class III-IV and/or left ventricular ejection fraction <40%, non-elective priority of surgery, peripheral arteriopathy, chronic renal failure) and intraoperative periods (on/off-pump performance). The Northern New England Cardiovascular Disease Study Group (NNECDSG) stroke risk schema was used to stratify stroke risk and compare observed neurological outcomes in this study. RESULTS: A total of 26 347 patients were included in the study. Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (OR = 2.37), peripheral arteriopathy (OR = 1.62), cardiac failure (OR = 2.98), prior stroke (OR = 1.57) and chronic renal failure (OR = 6.16) were found to be independent risk factors for perioperative stroke in uni- and multivariate models; Hosmer-Lemeshow test: χ(2) = 4.62, P = 0.59. Perioperative stroke incidence increased whenever NNECDSG score or the number of preoperative risk factors increased. However, on- vs off-pump surgery did not show statistical differences in NNECDSG strata. For patients with two or more preoperative independent risk factors, off-pump surgery showed a significant reduction in perioperative stroke incidence (4.29 vs 6.76%, P < 0.05), particularly when one of these factors was chronic renal failure or preoperative cardiac failure. However, when both factors were present concomitantly there was no difference between on and off-pump techniques, P < 0.0001. CONCLUSIONS: Off-pump surgery has a lower perioperative stroke incidence than on-pump only in cases associated with cardiovascular stroke-risk factors, in particular, with chronic renal failure and preoperative cardiac failure, but also with peripheral arteriopathy, prior stroke and non-elective surgery. The perioperative stroke rate remains high in cases with two or more preoperative stroke risk factors, even when using the off-pump technique, particularly when chronic renal failure is present.

Sistema de salud en Colombia: una revisión sistemática de literatura / Health system in Colombia: a systematic review of literature / Sistema de saúde na Colômbia: revisão sistemática de literatura

Problema: el Sistema General de Seguridad Social en Salud de Colombia, es objeto de críticaspor diferentes medios de opinión debido a sus altos costos de transacción, baja competitividady eficiencia. Surge entonces el interrogante sobre la contribución que hace la Academia colombianaa la reflexión sobre el sistema de salud durante sus veinte años de existencia. El objetivodel estudio fue el de caracterizar la contribución de publicaciones académicas a la reflexiónsobre el sistema de salud colombiano durante estos veinte años. Método: revisión sistemáticade literatura en la base de datos de Scielo entre 1993 y 2012, utilizando criterios de inclusión yexclusión. Resultados: 102 publicaciones cumplieron con los criterios de inclusión y exclusión.De estas publicaciones, dieciséis evalúan el sistema de salud de manera positiva o negativa. Loscriterios de inclusión y exclusión están detallados en la sección del método. Conclusiones: laspublicaciones se limitan a caracterizar el sistema de salud sin formular sugerencias ni modelosalternativos. Los trabajos académicos aparecen como poco relevantes para el debate nacional...

Problem: The Social Security System in Health of Colombia, is criticized by different mainstreammedia due to its high transaction costs, low competitiveness and efficiency. The question arisesabout the contribution made by the Colombian Academy on the reflection over the health systemduring its twenty years of existence. The aim of the study was to characterize the contributionof academic publications to the reflection on the Colombian health system over the last twentyyears. Method: systematic literature review in the SciELO database between 1993 and 2012,using inclusion and exclusion criteria. Results: 102 publications met the inclusion and exclusioncriteria. From these publications, sixteen evaluate the health system positively or negatively. Theinclusion and exclusion criteria are detailed in the method section. The Inclusion and exclusioncriteria are detailed in the method section. Conclusions: publications merely characterize thehealth system without making suggestions or alternative models. The academic papers are oflittle relevance to the national debate...

Problema: o Sistema Geral de Segurança Social em Saúde da Colômbia é objeto de críticaspor diferentes meios de opinião devido aos altos custos de transação, baixa competitividadee eficiência. Surge, então, a questão sobre a contribuição que a Academia colombiana faz àreflexão sobre o sistema de saúde durante seus vinte anos de existência. O objetivo do estudofoi o de caracterizar a contribuição de publicações acadêmicas à reflexão sobre o sistema desaúde colombiano durante estes vinte anos. Método: revisão sistemática de literatura na base dedados de Scielo entre 1993 e 2012, utilizando critérios de inclusão e exclusão. Resultados: 102publicações cumpriram com os critérios de inclusão e exclusão. Destas publicações, dezesseisavaliam o sistema de saúde de maneira positiva ou negativa. Os critérios de inclusão e exclusãoestão detalhados na seção do método. Conclusões: as publicações limitam-se a caracterizar osistema de saúde sem formular sugestões nem modelos alternativos. Os trabalhos acadêmicosaparecem como pouco relevantes para o debate nacional...

Dermatofitoma en tinea corporis con onicomicosis de pies y manos causados por Trichophyton rubrum / Dermatofitoma in tinea corporis with hand and foot onychomycosis caused by Trichophyton rubrum

Las dermatofitosis son infecciones crónicas de distribución mundial, las cuales pueden presentar ocasionalmente conglomerados de esporas, filamentos o ambos, denominadas ¨dermatofitomas¨. Se presentan un paciente que refiere tinea corporis de brazo derecho automedicado con corticosteroides tópicos, onicomicosis subungueal distal de manos y onicomicosis distrófica total de pies. En la observación microscópica directa se observaron dermatofitomas en el brazo y uñas de manos, y filamentos en las uñas de pies. Se identificó Trichophyton rubrum en brazo, unas de manos y pies.

Un caso infantil de tinea faciei por Trichophyton tonsurans en Guatemala / A child case of Trichophyton tonsurans tinea for faciei in Guatemala

El Trichophyton tonsurans es un dermatofito antropofílico de distribución mundial, asociado a brotes epidémicos de tinea capitis, pero que también se puede aislar en tinea ungueum y faciei. Se presenta un paciente de sexo masculino, de 3 años de edad, procedente de Guatemala, que tiene una lesión eritematosa de bordes bien definidos, con descamación gruesa en la mejilla derecha, de dos semanas de evolución, de la cual se aisló Trichophyton tonsurans. Curó luego del tratamiento con crema de ketoconazol al 2% durante 15 días.

Trichophyton tonsurans is an anthropophilic dermatophyte with a worldwide distribution that is associated with epidemic outbreaks of tinea capitis and sometimes it is also isolated from tinea ungueum and faciei. We report a 3 year-old male from Guatemala, with a two weeks history of a scaly erythematous lesion on the right cheek. Trichophyton tonsurans was isolated and the lesion resolved after a 15 days-course of 2% ketoconazole cream.

¿Por qué se limita la integración vertical en el sector salud en Colombia? / Por que é que se limita a integracao vertical no sector saúde na Colombia? / Why is vertical integration restricted in the Colombian health sector?

En el sector salud colombiano se busca limitar la integración vertical entre Entidades Promotoras de Salud (EPS) e Instituciones Prestadoras de Servicios de Salud (IPS), para evitar prácticas restrictivas de la competencia. Sin embargo, la evidencia empírica señala que no es concluyente el efecto de la integración vertical sobre la competencia entre aseguradoras. El trabajo plantea esta hipótesis sobre la base de la evidencia teórica y empírica, y muestra que la integración vertical no tuvo efectos sobre la competencia de las EPS del régimen contributivo en el período posterior a la aplicación de la restricción del 30% de contratación entre aseguradores y prestadores de servicios de salud...

In Colombia, the Health industry is restricted from vertically integrating the Health Management Organizations (EPS) with the Health Service Providers (IPS) in order to avoid antitrust competitive conditions. However, the empirical evidence in this regard is inconclusive. This paper analyzes this antitrust hypothesis, contrasting it to the empirical and theoretical evidence at hand, and shows that vertical integration had no effect on EPS competition in the period after the restriction on 30% contracting between both types of entities was enforced...

No sector saúde colombiano procura-se limitar a integração vertical entre Entidades Promotoras de Saúde (EPS) e Instituições Prestadoras de Serviços de Saúde (IPS) para evitar práticas restritivas da concorrência. No entanto, a evidência empírica indica que o efeito da integração vertical sobre a concorrência entre as companhias de seguros não é conclusivo. O trabalho levanta esta hipótese sobre a base da evidência teórica e empírica para mostrar que a integração vertical não teve nenhum efeito sobre a concorrência das EPS do regime contributivo no período após da aplicação da restrição de 30% de contratação entre as seguradoras e os prestadores dos serviços de saúde...