Reporting LDL cholesterol results by clinical biochemistry laboratories in Czechia and Slovakia to improve the detection rate of familial hypercholesterolemia.

Introduction: This survey aims to assess the implementation of recommendations from the European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) by clinical biochemistry laboratories in Czechia and Slovakia in their policies for reporting low-density lipoprotein cholesterol (LDL-C) concentrations. Materials and methods: The web-based survey was distributed to all 383 Czech and Slovak clinical biochemistry laboratories that measure lipids by external quality assessment provider SEKK. A total of 17 single-answer questions were included. The questionnaire was focused on the detection and decision points in familial hypercholesterolemia (FH). All survey answers were taken into account. The laboratories followed the EFLM and EAS guidelines when they reported an interpretative comment considering FH diagnosis in adults. Results: A total of 203 (53%) laboratories answered. Only 5% of laboratories added interpretative comments considering FH diagnosis when LDL-C concentrations are above 5.0 mmol/L in adults, and 3% of laboratories added interpretative comments considering FH diagnosis when LDL-C concentrations are above 4.0 mmol/L in children. Only 7% of laboratories reported goals for all cardiovascular risk categories (low, moderate, high, very high). Non-HDL cholesterol concentrations were calculated by 74% of responders. A significant number (51%) of participants did not measure apolipoprotein B, and 59% of laboratories did not measure lipoprotein(a). Conclusions: Only a small portion of laboratories from Czechia and Slovakia reported high LDL-C results with interpretative comments considering FH diagnosis in adults, the laboratories did not follow the guidelines.

Utilizing a Novel Pituitary Retractor for Early Descent of the Diaphragma Sellae during Endoscopic Transsphenoidal Pituitary Surgery.

OBJECTIVE: Early descent of the diaphragm sellae (DS) during endoscopic endonasal transsphenoidal surgery (EETS) for pituitary macroadenoma surgery is occasionally a troublesome event by blocking the surgical field. Here we introduce an alternative technique with the new pituitary retractor and present our clinical experiences. METHODS: We designed a simple and rigid pituitary retractor with the least space occupation in the nasal cavity to be compatible in EETS. The pituitary retractor was held by external holder system to support the herniated DS stably. We retrospectively reviewed a clinical 22 cases of pituitary macroadenomas underwent EETS using the pituitary retractor. RESULTS: The pituitary retractor stably pushed up the herniated DS in all cases, and the surgeon proceeded the procedure with bimanual maneuver. The pituitary retractor was helpful to remove tumors around the medial cavernous sinus and behind the DS in 16 and seven cases, respectively. In four cases, the meticulous hemostasis was completed with the direct visualization by the DS elevation with this retractor. Gross total tumor resection was performed in 20/22 patients (91%). The impaired visual function and hypopituitarism were improved in 18/20 (90%) and 7/14 (50%) patients after surgery, respectively. There was no complication related with the pituitary retractor. CONCLUSION: During EETS for pituitary macroadenomas, the novel pituitary retractor reported in this study is a very useful technique when the herniated DS block the surgical field and bimanual maneuver. This pituitary retractor can help to result in the excellent surgical outcomes with minimal morbidity.

Actions developed at the Instituto de Medicina Integral Prof. Fernando Figueira to confront the COVID-19 pandemic / Ações desenvolvidas no Instituto de Medicina Integral Prof. Fernando Figueira para enfrentamento à pandemia da COVID-19

Abstract The COVID-19 pandemic has brought countless challenges to the health institutions around the world, especially those located in countries such as Brazil, with large territorial dimensions and many social and economic differences. This technical report aims to publish the actions carried out and the products developed at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) before and during the pandemic - from January 31st to September 4th, 2020 - facing it efficiently and effectively, seeking institutional sustainability. The mobilization of the professional staff at the institution was fundamental to create protocols ofas-sistance, adapt the physical structures in the hospital and outpatient care, care for the health professionals, offer teaching and research activities in the distance mode, articulate management members to make decisions based on systematically collected data on the pandemic situationat real time. All actions were carried out with a single objective of assisting all the patients affected by COVID-19 admitted at the institution.

Resumo A pandemia da COVID-19 trouxe incontáveis desafios para as instituições de saúde de todo o mundo, em especial as localizadas em países como o Brasil, com grande dimensão territorial e muitas diferenças sociais e econômicas. Este informe técnico tem como objetivo publicizar as ações realizadas e os produtos desenvolvidos no Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) antes e durante a pandemia - no período de 31 de janeiro até 04 de setembro de 2020 - enfrentando-a com eficiência e eficácia, buscando a sustentabilidade institucional. A mobilização do corpo profissional da instituição foi fundamental para a construir protocolos de atendimento, adaptar as estruturas físicas na assistência ao paciente em âmbito hospitalar e ambulatorial, cuidar dos profissionais de saúde, ofertar as atividades de ensino e pesquisa na modalidade à distância, articular os membros da gestão para tomar decisões baseadas em dados sistematicamente coletados sobre a situação da pandemia em tempo real. Todas as ações foram realizadas com um uníssono objetivo de atender a todos os pacientes acometidos pela COVID-19 admitidos na instituição.

Self-reported occupational accidents and affecting factors among the adult population / Acidentes de trabalho autorreferidos e fatores que afetam a população adulta

Abstract Introduction As official occupational accident records are insufficient in developing countries such as Turkey, self-reported numbers are a better reflection of the real scope of occupational accidents among Turkish workers. Objective This study aims to determine the factors affecting occupational accidents in Turkey. Method This cross-sectional study re-evaluated data from a total of 42,360 participants, were obtained from the 'Occupational Accidents and Occupational Health Problems' module of the Household Labor Force Survey conducted by TurkStat. Results The prevalence of occupational accidents in the prior 12 months was 2.1%. The probability of an occupational accident for men was 1.78 times higher than for women (95% CI: 1.38-2.30). Workers who had not completed primary education [OR=1.91 (95% CI: 1.09-3.3)] and those who were divorced [OR=2.26 (95% CI: 1.40-3.63)] were more likely to have an accident at work, when compared to university graduates and unmarried employees, respectively. Conclusion Male gender, low educational level, and divorced marital status can be considered risk factors and require more attention and a control program to prevent the loss of labor due to occupational accidents in Turkey. This is the first, most comprehensive, and up-to-date study using extensive national data to examine the factors that affect occupational accidents in Turkey.

Resumo Introdução Como os registros oficiais de acidentes de trabalho são insuficientes em países em desenvolvimento, como a Turquia, os números autorrelatados refletem melhor o escopo real do acidente ocupacional entre os trabalhadores turcos. Objetivo Este estudo tem como objetivo determinar os fatores que afetam os acidentes de trabalho na Turquia. Método Estudo transversal que reavaliou dados de um total de 42.360 participantes, obtidos no módulo 'Acidentes de trabalho e problemas de saúde ocupacional' da Pesquisa da Força de Trabalho Doméstica realizada pela TurkStat. Resultados A prevalência de acidentes de trabalho nos últimos 12 meses foi de 2,1%. A probabilidade de um acidente de trabalho para homens foi 1,78 vezes maior que para mulheres (IC 95%: 1,38-2,30). Os trabalhadores que não concluíram o ensino fundamental [OR = 1,91 (IC 95%: 1,09-3,3)] e os que se divorciaram [OR = 2,26 (IC 95%: 1,40-3,63)] apresentaram maior probabilidade de sofrer um acidente de trabalho, quando comparados com graduados universitários e empregados solteiros, respectivamente. Conclusão O sexo masculino, o baixo nível educacional e o estado civil divorciado podem ser considerados fatores de risco e requerem mais atenção e um programa de controle para evitar a perda de trabalho devido a acidentes de trabalho na Turquia. Este é o primeiro, mais abrangente e atualizado estudo, a partir de extensos dados nacionais, para examinar os fatores que afetam os acidentes de trabalho na Turquia.

Cervical cancer prevention in Pernambuco: improvements for whom? Inequity scenario in the state of the Northeast Region / Prevenção do câncer do colo do útero: avanços para quem? Um retrato da iniquidade em estado da Região Nordeste

Abstract Objectives: to analyze the access to cervical cancer preventive examination in Pernambuco between 2002 and 2015 by cytopathological exam coverage. Methods: public data from SUS Computer Department were used, then processed by Tabnet and Excel and calculated the slope of the over time coefficient trend by simple regression techniques. Afterwards, they were plotted in thematic maps covering cytopathological exams on Terraview app 4.2.2. Results: Pernambuco State presented an increase of exam coverage trend in all the health regions until 2010. Since that year it started to have stabilization and decreased the tendency. Comparing the coverage of the two first years, in 2002, 42.7% of the cities coverage was below 0.2 and in 2015 the scenario changed, 41.1% of the cities coverage was above 0.6. We emphasize that even in that same year 13.5% of the cities still had a low or too low coverage (less than 0.4). The over time trends in increase and decline were strongly meaningful. Conclusions: this study revealed that all health regions presented a coverage lower than recommended, in some period or in all of them, even with the State growth tendency it demonstrated an unequal and heterogeneous characteristic.

Resumo Objetivos: analisar o acesso ao exame preventivo para o câncer de colo do útero em Pernambuco, entre 2002 e 2015, por meio da cobertura do citopatológico. Métodos: foram utilizados dados de domínio público do Departamento de Informática do SUS, processados no Tabnet e Excel® e calculados os coeficientes de inclinação de tendência temporal, por meio de técnicas de regressão simples. Por fim, foram plotados em mapas temáticos de cobertura de exames citopatológicos no aplicativo Terraview 4.2.2. Resultados: Pernambuco apresentou aumento na tendência de cobertura ao exame para todas as regiões de saúde até 2010. A partir deste ano, apresentou uma tendência de estabilização e diminuição. Ao comparar a cobertura no primeiro e no último ano, em 2002 42,7% dos municípios estavam com cobertura abaixo de 0.2 e em 2015 o cenário muda para 41,1% de municípios com cobertura acima 0.6. Destaca-se que neste mesmo ano 13,5% dos municípios ainda apresentavam uma cobertura baixa e muito baixa (<0.4). Tendências temporais de crescimento e decréscimo tiveram forte significância. Conclusões: todas as regiões de saúde apresentaram cobertura inferior ao preconizado, em algum período ou em todos, mesmo com a tendência estadual de crescimento, demonstrando uma característica heterogênea e desigual.

Ten-Step Minimally Invasive Cervical Decompression via Unilateral Tubular Laminotomy: Technical Note and Early Clinical Experience.

BACKGROUND: Minimally invasive techniques utilizing tubular retractors have become an increasingly popular approach to the spinal column. The concept of a unilateral laminotomy for bilateral decompression (ULBD), first applied in the lumbar spine, has recently been applied to the cervical spine for the treatment of cervical spondylotic myelopathy (CSM). A better understanding of the indications and surgical techniques is required to effectively educate surgeons on how to appropriately and safely perform tubular cervical laminotomy via ULBD. OBJECTIVE: To describe a 10-step technique for minimally invasive cervical laminotomy and report our early clinical experience. METHODS: A retrospective review identified 15 patients with CSM who were treated with this procedure. Visual analogue scale (VAS), neck disability index (NDI), and modified Japanese Orthopaedic Association (mJOA) scores were obtained pre- and postoperatively. RESULTS: The mean age of the 15 patients was 73.1 ± 6.8 yr. The median number of levels treated was 1 (range 1-3). Mean operative time was 125.3 ± 30.8 or 81.7 ± 19.2 min per level. Mean estimated blood loss was 57.3 ± 24.6 cc. Median postoperative hospital length of stay was 36 h. No complications were encountered. Median follow-up was 18 mo. Mean pre- and postoperative VAS were 6.4 ± 2.4 and 1.0 ± 0.8, respectively (P < .001). Mean pre- and postoperative NDI were 46.4 ± 19.2 and 7.0 ± 6.9, respectively (P < .001). Mean pre- and postoperative Mjoa were 11.3 ± 2.5 and 14.5 ± 0.5, respectively (P < .001). CONCLUSION: In our early clinical experience, minimally invasive cervical ULBD is safe and effective. Adherence to the presented 10-step technique will allow surgeons to safely address bilateral cervical pathology while avoiding complications.

Stereotactic Radiofrequency Thermocoagulation of Hypothalamic Hamartoma Using Robotic Guidance (ROSA) Coregistered with O-arm Guidance-Preliminary Technical Note.

INTRODUCTION: Treatment options for hypothalamic hamartoma (HH) include microvascular surgery, stereotactic radiofrequency thermocoagulation (SRT), laser interstitial thermal therapy, or Gamma Knife surgery. During SRT, thermographic monitoring cannot be performed and therefore highly accurate placement of electrode and confirmation of its position are required. We have used robotic guidance (ROSA) and coregistered it with O-arm for performing ablation of hamartoma. METHODS: Five patients with HH and gelastic seizures underwent SRT. Robotic guidance (ROSA) was used for placement of electrodes. An O-arm was used for coregistering and confirming the robotic trajectory with real-time intraoperative imaging. Intraoperative computed tomography was merged with preoperative magnetic resonance imaging to confirm the exact position and trajectory of the electrode. Ablation was performed using a radiofrequency generator (70°C for 60 seconds). Multiple target sites were ablated to achieve proper ablation and disconnection. RESULTS: Most patients (4/5) had International League Against Epilepsy class I outcome. One patient 2 sittings of lesioning. All but 1 electrode could be placed in the planned trajectories. One electrode was detected to have a medial deviation, and it had to be revised. No permanent complication was observed. CONCLUSIONS: SRT is a cost-effective method of treating HH when compared with laser interstitial thermal therapy. With the use of a robotic arm we have demonstrated accurate placement of electrodes. Intraoperative computed tomography acquired using an O-arm can be merged with preoperative magnetic resonance imaging. This confirms electrode location and trajectory on a real-time basis by performing intraoperative imaging. This method is safe and can be used for radiofrequency ablation of HH.

The effect of routine radiological reporting of thyroid incidentalomas on rates of thyroid needle biopsy, thyroid surgery and detection of thyroid malignancy.

OBJECTIVE: This study looked at the effect of a changing radiology reporting policy to routinely review the thyroid gland where visible and report on any thyroid lesion, recommending further investigation as appropriate. CONTEXT: Incidentaloma is a term used to describe a lesion found on imaging unrelated to the clinical issue under investigation. There is variability in the radiological reporting of thyroid incidentalomas and conflicting recommendations as to how these lesions should be managed. DESIGN: Data were collected retrospectively during a two-year period, including 12 months before and 12 months after the change in reporting policy and categorized according to whether the lesion under investigation was a thyroid incidentaloma or a symptomatic thyroid lesion. PATIENTS: All patients undergoing ultrasound-guided fine-needle aspiration cytology or core biopsy were included. MEASUREMENTS: The effects of the change in policy were analysed including rates of needle biopsy, rates of malignancy and subsequent surgical intervention. RESULTS: There was a 122% increase in thyroid incidentalomas undergoing needle biopsy, the majority of these were detected on computed tomography. The number of malignancies increased from 1 to 4 from year 1 to year 2. All patients were >35 years old. One patient had a positron emission tomography (PET)-detected cancer, two of four of the non-PET-detected malignancies were <1.5 cm. CONCLUSION: This study posits that routine radiological reporting of thyroid incidentalomas, with further investigation when clinically appropriate, is warranted. The results suggest that lesion size and CT characteristics are not reliable criteria to triage patients for investigation/biopsy.

Actions developed at the Instituto de Medicina Integral Prof. Fernando Figueira to confront microcephaly by Zika virus / Ações desenvolvidas no Instituto de Medicina Integral Prof. Fernando Figueira para enfrentamento à microcefalia pelo Zika vírus

Abstract Objectives: to publicize by inserting institutionally to the context of microcephaly care by Zika virus in the Northeast of Brazil and to describe the activities developed during the epidemic outbreak that occurred in the country in 2015. Methods: analysis on technical documents and institutional announcements in newspapers, on television and radio was carried out from August 2015 to July 2016. Results: the Central Nucleus to Monitor and Study Microcephaly at Instituto de Medicina Integral Prof. Fernando Figueira (IMIP); took part in elaborating a Clinical and Epidemiological protocol for Professionals at Maternity Hospitals and Referral Services from the State Health Department of Pernambuco (SES/PE); IMIP became a National Referral Center in elaborating protocols to identify and monitor children with microcephaly, and a Benchmark Assistance for the State Health Department of Pernambuco. Technical meetings took place with the participation of clinical and medical professionals, researchers, professors and institutional managers, forums, training sessions and workshops along with national and international institutions, technical visits of international organizations and development of studies on Zika virus and microcephaly. Conclusions: the impact by notifying microcephaly cases caused mobilization of services at IMIP, reorganization of work processes and research developments.

Resumo Objetivos: publicizar a inserção institucional no contexto da atenção à microcefalia pelo vírus Zika na Região Nordeste do Brasil e descrever as atividades desenvolvidas durante o surto epidêmico ocorrido no país em 2015. Métodos: realizada análise de documentos técnicos e de divulgação institucionais e de registros da mídia impressa, televisiva e de rádio no período de agosto de 2015 a julho de 2016. Resultados: instituído o Núcleo Central de Monitoramento e Estudo da Microcefalia do Instituto de Medicina Integral Prof. Fernando Figueira (IMIP); participação na elaboração de Protocolo Clínico e Epidemiológico para Profissionais de Maternidades e Serviços de Referência pela Secretaria Estadual de Saúde de Pernambuco (SES/PE); IMIP tornou-se Centro de Referência Nacional na Elaboração de Protocolos para Identificação e Acompanhamento de Crianças com Microcefalia e Referência Assistencial para a SES/PE. Realizadas reuniões técnicas com a participação dos profissionais clínicos, pesquisadores, docentes e gestores da instituição, fóruns, treinamentos e oficinas de trabalho com instituições nacionais e internacionais, visita técnica de organismos internacionais e desenvolvimento de estudos sobre vírus Zika e microcefalia. Conclusões: o impacto causado pela notificação dos casos de microcefalia provocou mobilização dos serviços do IMIP, reorganização dos processos de trabalho e desenvolvimento de pesquisas.

Nonshaved cranial surgery in black Africans: technical report and a medium-term prospective outcome study.

Nonshaved neurosurgery, cranial or spinal, is well reported among Caucasians but hardly among native Africans. The ungroomed scalp hairs of black Africans have unique anthropological characteristics needing special attention for shaveless cranial surgery. A technical report of the execution of this surgical procedure among an indigenous patient population in a sub-Sahara African country is presented, as well as an outcome analysis in a prospective cohort over a 7-year period. A total of 303 patients (211 males, 70 %) fulfilled the criteria for this study. The surgical procedure was primary in 278 (92 %) and redo in 8 %. It was emergency surgery in 153 (51 %). They were trauma craniotomies or decompressive craniectomies in 95 cases (31 %), craniotomies for tumour resections in 86 (28 %), and the surgical dissections for other conditions in 122 (41 %). The duration of surgery ranged from 30 min to 8.5 h, mean 2.5 (SD, 1.6), median 2. In-hospital clinical outcome was good (normal status or moderate deficit on dichotomized Glasgow outcome scale (GOS)) in 273 (90.1 %) cases while surgical site infections occurred in only 10 cases (3.3 %). The type of surgery, redo or primary, did not have any significant association with the in-hospital outcome (p = 0.5), nor with the presence of surgical site infection (SSI) (p = 0.7). The length of follow-up ranged from 2 to 63 months (mean, 7) with no untoward complications reported so far. Medium-term outcome of nonshaved neurosurgery in this indigenous black Africans remains favourable with no attendant significant adverse after-effects.

A novel intra-operative, high-resolution atrial mapping approach.

PURPOSE: A new technique is demonstrated for extensive high-resolution intra-operative atrial mapping that will facilitate the localization of atrial fibrillation (AF) sources and identification of the substrate perpetuating AF. METHODS: Prior to the start of extra-corporal circulation, a 8 × 24-electrode array (2-mm inter-electrode distance) is placed subsequently on all the right and left epicardial atrial sites, including Bachmann's bundle, for recording of unipolar electrograms during sinus rhythm and (induced) AF. AF is induced by high-frequency pacing at the right atrial free wall. A pacemaker wire stitched to the right atrium serves as a reference signal. The indifferent pole is connected to a steal wire fixed to subcutaneous tissue. Electrograms are recorded by a computerized mapping system and, after amplification (gain 1000), filtering (bandwidth 0.5-400 Hz), sampling (1 kHz) and analogue to digital conversion (16 bits), automatically stored on hard disk. During the mapping procedure, real-time visualization secures electrogram quality. Analysis will be performed offline. RESULTS: This technique was performed in 168 patients of 18 years and older, with coronary and/or structural heart disease, with or without AF, electively scheduled for cardiac surgery and a ventricular ejection fraction above 40 %. The mean duration of the entire mapping procedure including preparation time was 9 ± 2 min. Complications related to the mapping procedure during or after cardiac surgery were not observed. CONCLUSIONS: We introduce the first epicardial atrial mapping approach with a high resolution of ≥1728 recording sites which can be performed in a procedure time of only 9±2 mins. This mapping technique can potentially identify areas responsible for initiation and persistence of AF and hopefully can individualize both diagnosis and therapy of AF.

Anterograde and retrograde epidural paddle placement through a single laminotomy for the treatment of back and lower extremity pain using spinal cord stimulation: case reports and technical note.

OBJECTIVE: Spinal cord stimulation can be effectively used in the treatment of low back pain and extremity pain in failed back surgery syndrome. Ideal targets for stimulation corresponding to paresthesia overlap in the low back versus the extremities may differ in cranial-caudal location. MATERIALS AND METHODS: We present here a technical report of three cases demonstrating a technique to place anterograde and retrograde epidural paddles through a single laminotomy. RESULTS: Using this technique we were able to cover five spinal levels in each patient, and different stimulation programs at different levels created paresthesia overlap in back versus lower extremity in those patients. CONCLUSION: Dual paddle placement through a single laminotomy may be a reasonable option for select patients where coverage of anatomically-separated pain regions is necessary. This technique can be performed in most patients without significantly increased morbidity.

Leishmaniasis cutánea americana en Venezuela, bienio 2008-2009 / American cutaneous leishmaniasis in Venezuela, biennium 2008-2009

Se presenta el reporte epidemiológico de la Leishmaniasis Cutánea Americana (LCA) en Venezuela para los años 2008-2009. Se describen las características epidemiológicas generales, junto a algunos aspectos clínico-inmunológicos de sus diferentes formas clínicas. Esto se logro a través del análisis de la base de datos del registro nacional de leishmaniasis del Instituto de Biomedicina. La información fue analizada con Epi Info 3.5.1 y Excel. Un total de 4.640 casos de las diferentes formas clínicas de leishmaniasis cutánea fueron diagnosticados en el periodo 2008-2009, una media de 2.320 casos por año, con una tasa promedio anual de 8,25 por 100.000 habitantes. Predomina el sexo masculino con una razón de masculinidad de 1,84 para el periodo en estudio. Casos en todas las edades, con predominio numérico en el grupo de 5 a 34 años, edad promedio fue de 31,09 y 33,91 años para 2008 y 2009 respectivamente. En cuanto a la ocupación 22,39 % corresponde a personas del sector agropecuario, seguido de estudiantes con 20,88% de los casos. Se registraron casos en todas las entidades federales menos en Nueva Esparta, en este periodo los estados con mayor número de casos fueron, Lara con 910 (19,61%), Miranda con 650 (14,01%) y Táchira con 488 (10,52%). En cuanto a las formas clínicas se observó un predominio franco de la leishmaniasis cutánea localizada con 97,84% de los casos (4.540/4.640). Mientras que las formas localizadas están distribuidas por todo el territorio nacional, las formas difusas predominan en el estado Lara (63,64%, 7/11), las formas Mucosas en los estados Bolívar (21,74%, 10/46), Portuguesa (15,22%, 7/46) y Miranda, Táchira, Zulia (10,87%, 5/46 c/u) y finalmente las formas intermedias en los estados Monagas (30,23%, 13/43), Miranda (18,60%, 8/43) y Táchira (13,95%, 6/43). Las características clínicas e inmunológicas estudiadas variaron de acuerdo con las diferentes formas clínicas. En promedio más del 90 % (93,39 % en el 2008 y 89,81 % en el 2009) de los casos fueron diagnosticados con frotis directo. 88,86 % de los casos recibieron como tratamiento de primera elección inmunoterapia. En conclusión se hace una descripción clínico-epidemiológica de la LCA en Venezuela para el periodo 2008-2009 y se compara con el patrón descrito con anterioridad.

The epidemiological report of American Cutaneous Leishmaniasis (ACL) in Venezuela for the years 2008-2009 is presented. It describes the general epidemiological characteristics, together with some clinical and immunological aspects of its different clinical forms. This was performed by analyzing the database of the leishmaniasis national registry of the Instituto de Biomedicina. The data was analyzed using Epi Info 3.5.1 and Excel. A total of 4,640 cases of different clinical forms of cutaneous leishmaniasis were diagnosed during 2008-2009, i. e. 2,320 cases per year with an average annual rate of 8.25 per 100,000 inhabitants. It is predominant in males, with a sex ratio of 1.84 for the period under study. Cases in all ages, with numerical predominance in the group of 5 to 34 years, mean age were 31.09 and 33.91 years for 2008 and 2009 respectively. Regarding the occupation, 22.39% are people of the agricultural sector, followed by students with 20.88% of cases. Cases were recorded in all states but Nueva Esparta, the states with the largest number of cases were Lara with 910 (19.61%), Miranda 650 (14.01%) and Táchira with 488 (10.52%). In terms of clinical forms, clear predominance was observed of localized cutaneous leishmaniasis with 97.84 % (4,540) cases. While localized forms are distributed nationwide, diffuse forms predominate in the Lara State (63.64%, 7/11), muco-cutaneous forms predominate in the States of Bolivar (21.74%, 10/46), Portuguesa (15.22%, 7/46) and Miranda, Táchira, Zulia (10.87%, 5/46 each one) and finally, the intermediate forms in the States of Monagas (30.23%, 13/43), Miranda (18.60%, 8/43) and Táchira (13.95%, 6/43). The clinical and immunological characteristics studied varied according to the different clinical forms. In average, more than 90% (93.39% in 2008 and 89.81% in 2009) of the cases were diagnosed with direct smear. 88.86% of the patients received immunotherapy as first choice treatment. In conclusion, a clinical-epidemiological description of the ACL in Venezuela for the period 2008-2009 was made and compared with the pattern previously described.

Individual health services.

BACKGROUND: The German statutory health insurance (GKV) reimburses all health care services that are deemed sufficient, appropriate, and efficient. According to the German Medical Association (BÄK), individual health services (IGeL) are services that are not under liability of the GKV, medically necessary or recommendable or at least justifiable. They have to be explicitly requested by the patient and have to be paid out of pocket. RESEARCH QUESTIONS: The following questions regarding IGeL in the outpatient health care of GKV insurants are addressed in the present report: What is the empirical evidence regarding offers, utilization, practice, acceptance, and the relation between physician and patient, as well as the economic relevance of IGeL?What ethical, social, and legal aspects are related to IGeL? FOR TWO OF THE MOST COMMON IGEL, THE SCREENING FOR GLAUCOMA AND THE SCREENING FOR OVARIAN AND ENDOMETRIAL CANCER BY VAGINAL ULTRASOUND (VUS), THE FOLLOWING QUESTIONS ARE ADDRESSED: What is the evidence for the clinical effectiveness?Are there sub-populations for whom screening might be beneficial? METHODS: The evaluation is divided into two parts. For the first part a systematic literature review of primary studies and publications concerning ethical, social and legal aspects is performed. In the second part, rapid assessments of the clinical effectiveness for the two examples, glaucoma and VUS screening, are prepared. Therefore, in a first step, HTA-reports and systematic reviews are searched, followed by a search for original studies published after the end of the research period of the most recent HTA-report included. RESULTS: 29 studies were included for the first question. Between 19 and 53% of GKV members receive IGeL offers, of which three-quarters are realised. 16 to 19% of the insurants ask actively for IGeL. Intraocular tension measurement is the most common single IGeL service, accounting for up to 40% of the offers. It is followed by ultrasound assessments with up to 25% of the offers. Cancer screening and blood or laboratory services are also frequent and represent a major proportion of the demand. The ethical, social, and legal aspects discussed in the context of IGeL concern eight subject areas: autonomous patient decisions versus obtrusion,commercialization of medicine, duty of patient information, benefit, evidence, and (quality) control, role and relation of physicians and patients,relation to the GKV, social inequality,formally correct performance. For glaucoma screening, no randomized controlled trial (RCT) is identified that shows a patient relevant benefit. For VUS three RCT are included. However, they do not yet present mortality data concerning screened and non-screened persons. VUS screening shows a high degree of over-diagnosis in turn leading to invasive interventions. To diagnose one invasive carcinoma, 30 to 35 surgical procedures are necessary. CONCLUSION: IGeL are a relevant factor in the German statutory health care system. To provide more transparency, the requests for evidence-based and independent patient information should be considered. Whether official positive and negative-lists could be an appropriate instrument to give guidance to patients and physicians, should be examined. Generally, IGeL must be seen in the broader context of the discussions about the future design and development of the German health care system.

Informative value of Patient Reported Outcomes (PRO) in Health Technology Assessment (HTA).

BACKGROUND: "Patient-Reported Outcome" (PRO) is used as an umbrella term for different concepts for measuring subjectively perceived health status e. g. as treatment effects. Their common characteristic is, that the appraisal of the health status is reported by the patient himself. In order to describe the informative value of PRO in Health Technology Assessment (HTA) first an overview of concepts, classifications and methods of measurement is given. The overview is complemented by an empirical analysis of clinical trials and HTA-reports on rheumatoid arthritis and breast cancer in order to report on type, frequency and consequences of PRO used in these documents. METHODS: For both issues systematic reviews of the literature have been performed. The search for methodological literature covers the publication period from 1990 to 2009, the search for clinical trials of rheumatoid arthritis and breast cancer covers the period 2005 to 2009. Both searches were performed in the medical databases of the German Institute of Medical Documentation and Information (DIMDI). The search for HTA-reports and methodological papers of HTA-agencies was performed in the CRD-Databases (CRD = Centre for Reviews and Dissemination) and by handsearching the websites of INAHTA member agencies (INAHTA = International Network of Agencies for Health Technology Assessment). For all issues specific inclusion and exclusion criteria were defined. The methodological quality of randomized controlled trials (RCT) was assessed by a modified version of the Cochrane Risk of Bias Tool. For the methodological part information extraction from the literature is structured by the report's chapters, for the empirical part data extraction sheets were constructed. All information is summarized in a qualitative manner. RESULTS: Concerning the methodological issues the literature search retrieved 158 documents (87 documents related to definition or classification, 125 documents related to operationalisation of PRO). For the empirical analyses 225 RCT (rheumatoid arthritis: 77; breast cancer: 148) and 40 HTA-reports and method papers were found. The analysis of the methodological literature confirms the role of PRO as an umbrella term for a variety of different concepts. The newest classification system facilitates the description of PRO measures by construct, target population and the method of measurement. Steps of operationalisation involve defining a conceptual framework, instrument development, exploration of measurement properties or, possibly, the modification of existing instruments. Seven out of 59 RCT analysing the effects of antibody therapy for rheumatoid arthritis define PRO as the primary endpoint, 38 trials utilize composite measures (ACR, DAS) and ten trials report clinical or radiological parameters as the primary endpoint. Six out of 123 chemotherapy trials for breast cancer define PRO as the primary endpoint, while 98 trials report clinical endpoints (survival, tumour response, progression) in their primary analyses. Discrepancies in the number of trials result from inaccurate specifications of endpoints in the publications. This distribution is reflected in the HTA-reports: while almost all reports on rheumatoid arthritis refer to PRO, this is only the case in about half of the reports on breast cancer. CONCLUSIONS: As definition and classification of PRO are concerned, coherent concepts are found in the literature. Their operationalisation and implementation must be guided by scientific principles. The type and frequency of PRO used in clinical trials largely depend on the disease analysed. The HTA-community seems to pursue the utilization of PRO proactively - in case of missing data the need for further research is stated.

Dosimetric evaluation of a three-dimensional treatment planning system.

The computerized treatment planning system plays a major role in radiation therapy in delivering correct radiation dose to the patients within ±5% as recommended by the ICRU. To evaluate the dosimetric performance of the Treatment Planning system (TPS) with three-dimensional dose calculation algorithm using the basic beam data measured for 6 MV X-rays. Eleven numbers of test cases were created according to the Technical Report Series-430 (TRS 430) and are used to evaluate the TPS in a homogeneous water phantom. These cases involve simple field arrangements as well as the presence of a low-density material in the beam to resemble an air in-homogeneity. Absolute dose measurements were performed for the each case with the MU calculation given by the TPS, and the measured dose is compared with the corresponding TPS calculated dose values. The result yields a percentage difference maximum of 2.38% for all simple test cases. For complex test cases in the presence of in-homogeneity, beam modifiers or beam modifiers with asymmetric fields a maximum percentage difference of 5.94% was observed. This study ensures that the dosimetric calculations performed by the TPS are within the accuracy of ±5% which is very much warranted in patient dose delivery. The test procedures are simple, not only during the installation of TPS, but also repeated at periodic intervals.

HIV testing in the workplace: clarifying the meaning of South Africa's Employment Equity Act.

PIP: This article clarifies the meaning of South Africa's Employment Equity Act, which includes HIV testing in the workplace. This historic piece of legislation is intended to promote equality and equal opportunity in the workplace. Among other things, the Act prohibits employers to conduct pre-employment HIV testing unless the Labor Court has given permission. Several interpretations have ensued which was seen as damaging to HIV prevention strategies in the workplace. Employers, likewise, have used these interpretations to justify a threat to withdraw from the Joint UN Program on the HIV/AIDS-Sponsored Greater Involvement of People Living with HIV/AIDS program. Similarly, arguments for HIV testing followed which were based on a fancifully narrow and literal reading of the section. This resulted to the literal interpretation of the Act that eventually made the contested sections unconstitutional and deprived employees of their fundamental rights to freedom and security, and access to health care services. A non-literal interpretation of the Act, on the other hand, does require the prohibition as applying only to ¿employer-initiated¿ HIV testing. One immediate remedy to the confusion would be for the Employment Equity Commission to publish a code of good practice on HIV testing in the workplace.^ieng

WHO blames lack of governments' support for unsafe blood supply.

PIP: The WHO reported that more than half of the world's countries fail to perform full tests on donated blood, increasing the risk of spreading AIDS and other diseases. It has been estimated that about 5-10% of people with HIV were infected via blood transfusions. The noncompliance of the WHO guidelines on blood donation screening mostly occurs in developing countries, which the WHO concedes as expensive. In the next 5 years, WHO is planning to install, or to assist member states in installing, a national blood safety program to help offset the infected blood supply. On the other hand, nongovernmental organizations like the Red Cross encourages blood donors to be honest with health workers in describing any diseases and ensure that their blood does not endanger the health of the recipient. The WHO, likewise, proposes to bulk-buy testing kits for developing countries, and provide extensive training and program development.^ieng

AIDS in Africa: a regional overview.

PIP: This document provides a regional overview on the AIDS epidemic in the African continent. A widespread difference between regions in the incidence of AIDS has been associated with the socioeconomic and cultural differences. The highest occurrence of AIDS was reported in the three-nation cluster of Namibia, Botswana, and Zimbabwe found in the region of sub-Saharan Africa. A specific subtype C of HIV-1 is transmitted easier through heterosexual intercourse, while mother-to-infant transmission had been the second most common mode of transmission. In the 1998 report of the UN Joint Programme on HIV/AIDS, the prevalence of AIDS was relatively moderate in central Africa, with a low occurrence of HIV-1 subtypes A, C, D, F, G, H, I, J, O, and U. Eastern Africa was found to have the HIV-1 subtypes A and D, with the subtype C making its existence known. Active government prevention programs and strong Islam influence had resulted in a minimal incidence of HIV transmission in western Africa. A rare, less infectious form HIV-2 had been discovered in western African nations like Senegal, Mauritania, and Cape Verde. Northern Africa thus far had eluded the level of devastation that inflicted the other regions, but with the large population of immigrant workers, sex tourism, and injection drug use, increasing incidence of HIV infection is making its presence felt. Government and nongovernmental organizations are making efforts in the prevention and education of those specifically at high risk for infection.^ieng

POPs culture.

PIP: This paper focuses on the form of industrial innovation that is continually producing persistent organic pollutants (POPs), which are toxins so potent and durable that emissions may be causing cancer and birth defects 1000 years from now. POPs have five properties; they are persistent, organic, polluting, fat-soluble, and occur in the environment in forms that allow them to travel great distances. It is noted that POPs are very dangerous; however, it is difficult to assess the public health risks of these toxins. In addition, the apparent randomness of the threat is exacerbated by the fact that injury is often delayed or indirect. While POPs are toxic by definition, their long-term health and environmental impacts are still largely unknown. Reducing the risks from the vast and growing number of synthetic chemicals that are being released into the environment requires the rethinking of some of the basic notions of industrial development. Although efforts have been made to address this problem using the regulatory approach, much work is still needed in this area. A fundamental reform or a change that goes far deeper than conventional regulation is recommended. The precautionary principle is advocated.^ieng