[Cost-effectiveness analysis of fracture liaison services in Catalonia]. / Análisis de coste-efectividad de las Unidades de Coordinación de Fracturas en Cataluña.

OBJECTIVE: To assess the cost-effectiveness of Fracture Liaison Service (FLS) compared to the standard of care for secondary prevention of fragility fractures form the perspective of the Catalan Health Service. METHODS: Cost-utility assessment through a Markov model that simulated disease progression of a patients' cohort candidates to initiate antiosteoporotic treatment after a fragility fracture. A time horizon of 10 years and a 6-month duration per cycle was established. Clinical, economics and quality of life parameters were obtained from the literature and derived from four Catalan FLS. The Catalan Health Service perspective was adopted, considering direct health costs expressed in 2022 euros. A 3% discount rate was applied on costs and outcomes. Uncertainty was assessed through multiple sensitivity analyses. RESULTS: Compared to the standard of care, FLS would promote antiosteoporotic initiation and persistence, reducing the incidence and mortality associated with subsequent fragility fractures. This incremental clinical benefit was estimated at 0.055 years and 0.112 quality-adjusted life years (QALYs) per patient. A higher cost (€1,073.79 per patient) was estimated, resulting into an incremental cost-utility ratio of €9,602.72 per QALYs gained. The sensitivity analyses performed were consistent, corroborating the robustness and conservative approach of the base-case. CONCLUSIONS: The introduction of FLS for the secondary prevention of FF would represent a cost-effective strategy from the Catalan Health Service perspective.

Partial or total replacement of commercial concentrate with on-farm-grown mulberry forage: effects on lamb growth and feeding costs.

Replacing commercial concentrate with mulberry foliage was evaluated in a feeding trial lasting 126 days. Forty-eight weaned male Pelibuey lambs (20.6 ± 0.80 kg of BW) were randomly allocated to four groups: (1) supplementing the basal diet with mulberry at 1% (DM basis; M-1), (2) mulberry at 0.75% plus 0.1 kg concentrate fresh matter basis (M-0.75), (3) mulberry at 0.50% plus 0.2 kg concentrate (M-0.50) and (4) basal diet plus 0.3 kg concentrate (control; M-0). During the first 90 days, the basal diet was Pennisetum purpureum forage which was substituted by a mixture of guinea grass and sugarcane from 90 days. Average daily gain (ADG, g/day), dry matter intake (DMI) and feed conversion rate (FCR; DMI/ADG) were determined. The ADG was affected (P < 0.01) by the diet, with the lowest obtained in M-1 lambs (71 ± 6.4 g/day), whereas no differences among the other groups were observed (94 ± 6.4 g DM/lamb). The DMI was higher (P < 0.01) in M-0 (937 g DM/lamb) which concomitantly affected differences in FCR (11.9, 9.9, 10.5 and 9.7 kg DMI/kg BW gain for M-1, M-0.75, M-0.50 and M-0 lambs, respectively). Final BW at slaughtering and hot or cold carcass yields were coherent with growth rate findings. Biological yield (cold carcass weight/empty BW) was higher (P < 0.01) in M-0.75. Without compromising animal productivity, replacing imported concentrate with mulberry reduced the feeding cost. Optimum results were obtained with M-75 diet. Further studies must be conducted for optimizing energy/protein ratios with different ingredients while increasing DMI and lamb growth rates in this tropical genotype.

Limited value of ultrasound assessment in patients with poor outcome after carpal tunnel release surgery.

OBJECTIVE: To determine the value of ultrasonography in the assessment of patients with idiopathic carpal tunnel syndrome (CTS) and poor outcome after carpal tunnel release. METHODS: A total of 88 consecutive patients with CTS (104 hands) underwent open surgical release of the median nerve. Ultrasound (US) examination was performed blind to any patient's data. The median nerve area at tunnel inlet and outlet, the retinaculum distance, and the flattening ratio were measured. The main outcome variable was the patient's overall satisfaction using a five-point Likert scale (1 = worse, 2 = no change, 3 = slightly better, 4 = much better, 5 = cured) at 3 months postoperatively. Pre- and postoperative ultrasonographic findings in relation to clinical outcome were analysed. RESULTS: Improvement (scores 4 or 5 on the Likert scale) was recorded in 75 hands (72%). After carpal tunnel release, the cross-sectional area at tunnel inlet decreased from a mean of 14.2 to 13.3 mm2 in the group with clinical improvement and also from a mean of 12.5 to 11.6 mm2 in the group with no change or slight improvement. No significant changes in the cross-sectional area at tunnel outlet, retinaculum distance, and flattening ratio were observed. CONCLUSION: Reduction of the median nerve cross-sectional area at tunnel inlet at 3 months after carpal tunnel release was similar in patients reporting cure or great improvement and in those with slight or no improvement. Ultrasonography is of limited value in assessment of patients with poor outcome after median nerve release.

Disparities in rheumatoid arthritis disease activity according to gross domestic product in 25 countries in the QUEST-RA database.

OBJECTIVE: To analyse associations between the clinical status of patients with rheumatoid arthritis (RA) and the gross domestic product (GDP) of their resident country. METHODS: The Quantitative Standard Monitoring of Patients with Rheumatoid Arthritis (QUEST-RA) cohort includes clinical and questionnaire data from 6004 patients who were seen in usual care at 70 rheumatology clinics in 25 countries as of April 2008, including 18 European countries. Demographic variables, clinical characteristics, RA disease activity measures, including the disease activity score in 28 joints (DAS28), and treatment-related variables were analysed according to GDP per capita, including 14 "high GDP" countries with GDP per capita greater than US$24,000 and 11 "low GDP" countries with GDP per capita less than US$11,000. RESULTS: Disease activity DAS28 ranged between 3.1 and 6.0 among the 25 countries and was significantly associated with GDP (r = -0.78, 95% CI -0.56 to -0.90, r(2) = 61%). Disease activity levels differed substantially between "high GDP" and "low GDP" countries at much greater levels than according to whether patients were currently taking or not taking methotrexate, prednisone and/or biological agents. CONCLUSIONS: The clinical status of patients with RA was correlated significantly with GDP among 25 mostly European countries according to all disease measures, associated only modestly with the current use of antirheumatic medications. The burden of arthritis appears substantially greater in "low GDP" than in "high GDP" countries. These findings may alert healthcare professionals and designers of health policy towards improving the clinical status of patients with RA in all countries.

Improved cardiac function in patients with obstructive jaundice after internal biliary drainage: hemodynamic and hormonal assessment.

OBJECTIVE: To investigate myocardial function in patients with obstructive jaundice before and after internal biliary drainage. SUMMARY BACKGROUND DATA: Increased plasma levels of atrial natriuretic peptide (ANP) have been found in patients with biliary obstruction. METHODS: Thirteen patients with newly diagnosed obstructive jaundice and no previous heart, lung, or renal disease were studied using a Swan-Ganz catheter. Hemodynamic measurements were taken before and 4 days after internal biliary drainage. Levels of ANP and brain natriuretic peptide (BNP) were obtained and liver function tests were also determined. RESULTS: Plasma levels of ANP and BNP were increased twofold to fourfold in the basal state and declined after biliary drainage. Independent variables predicting left ventricular systolic work were total bilirubin concentrations, duration of jaundice, and BNP. In addition, bilirubin concentrations correlated with pulmonary vascular resistance, mean arterial pulmonary pressure, and right ventricular systolic work. Internal biliary drainage resulted in an improvement in left ventricular systolic work. A correlation was found between decreasing ANP concentrations and increasing cardiac output. CONCLUSIONS: Increased plasma levels of natriuretic peptides in patients with obstructive jaundice may reflect a subclinical myocardial dysfunction correlating with the degree of jaundice. After internal biliary drainage, there is a measurable improvement of cardiac function.

Preoperative assessment of body fluid disturbances in patients with obstructive jaundice.

Postoperative renal dysfunction in obstructive jaundice (OJ) patients has been associated with hypovolemia and depletion of the extracellular water compartment (ECW). The aim of the study was to evaluate the preoperative status of body compartments in OJ patients measured by two methods. In a prospective study 39 OJ patients (11 benign and 28 malignant obstructions) were investigated, with 15 healthy subjects used as a control group (CG). Bioelectrical impedance analysis (BIA) determinations and values derived from anthropometric measurements were used to assess body compartment status. The coefficient of variation of BIA was below 4% in both OJ and CG subjects. No differences were found in intracellular water. However total body water (TBW) and ECW were reduced in OJ patients (50.5 +/- 4.6 vs. 56 +/- 8% body weight, p = 0.05; and 21 +/- 4.5 vs. 23.8 +/- 2.5% body weight, p < 0.05, respectively). There were no differences between benign and malignant obstructions. Seventy four percent of OJ patients had an ECW volume below the mean +/- 2 SD in the CG subjects. Anthropometric and BIA determinations correlated closely for TBW measurements in both CG (r = 0.92, p < 0.001) and OJ patients (r = 0.91, p < 0.001). Bland-Altman analysis also showed that for TBW the BIA was in agreement with anthropometry. In the present study, BIA offered a good correlation with anthropometric determinations and was a reliable method for body fluid disturbances assessment in jaundiced patients.

[A preventive medical survey among workers in Quito]. / Una encuesta medico-preventiva entre obreros de Quito.

PIP: A government mobile health team trained in preventive medicine made up of 2 doctors, a nurse, 2 social workers, and a secretary vistied 50 factories in 16 months for the purpose of doing thorough physicals on workers. Blood, urine, stool, and X-ray studies were done. 4374 persons were examined from a possible group of 4900. The number of treatments given as a result of the exams was, however, greater than the number of exams because many cases required prolonged therapy. The patients were of low socioeconomic status and it was found that parasitosis, infection, malnutrition, and anemia were all contributing to their poor state of health. Most of the food they consumed while working lacked vital nutrients and was purchased from open air stalls without any sort of sanitary control. A rather high incidence of syphilis was noted and incidence of TB, though low, was also felt to be noteworth. Most of the illnesses discovered were cardiovascular, pneumonological; ophthalmological, and otorinolaringytic. A need for preventive medical facilities at places of work was evident.^ieng