Treatment compliance in chronic illness: Current situation and future perspectives. / Adherencia terapéutica en la enfermedad crónica: estado de la situación y perspectiva de futuro.

Long-term chronic diseases have a high mortality rate around the world, affecting both genders equally. Despite improvements in the diagnosis and treatment of various health problems, lack of treatment compliance remains an obstacle to improving health and patient quality of life, and it carries a high associated socio-healthcare cost. The objectives of this study were to develop the concept of «therapeutic adherence¼, which includes both pharmacological compliance as well as non-pharmacological (level of agreement and patient involvement, lifestyle changes, etc.) treatments. The study also aimed to establish the clinical and socio-health impact of non-compliance, the reasons for non-compliance, and methods and strategies to improve compliance. The results of this study support therapeutic adherence as an essential goal of the healthcare system that encompasses all stakeholders involved in patient health.

Severa descompensación por virus de hepatitis E en una paciente con hepatitis autoinmune: reporte de un caso / Severe decompensated hepatitis E virus in a patient with autoimmune hepatitis: a case report

Reportamos el caso de una paciente en quien se hizo inicialmente el diagnóstico de infección aguda por virus de hepatitis E por presentar un cuadro de ictericia con elevación de enzimas hepáticas e IgM VHE (+), pero por evolución crónica (Más de 6 meses) y sin ser una paciente inmunosuprimida; nos obligó a descartar causas diferentes que podrían producir enfermedad hepática crónica. Se detectó hipergamaglobulinemia y en biopsia hepática: hepatitis de interface, infiltrado inflamatorio mixto a predominio de linfocitos, y presencia de tractos fibrosos porta-porta, cambios sugestivos de hepatitis crónica severamente activa que podría ser secundaria a hepatitis autoinmune asociada a infección por virus de hepatitis E. Con estos hallazgos se decidió iniciar tratamiento para hepatitis autoinmune con Prednisona y Azatioprina, produciéndose una disminución de las transaminasas y perfil de coagulación hasta la normalidad, lo que ayudó a confirmar el diagnostico de hepatitis autoinmune descompensada y puesta de manifiesto por una infección aguda por virus de hepatitis E. Presentamos el caso clínico completo y una revisión de la literatura.

We report the case of a patient wo initially made the diagnosis of acute hepatitis E virus with a clinical picture of jaundice with elevated liver enzymes and HEV IgM (+), but chronic evolution (More than 6 months) without being an immunosuppresed patient, forced us to exclude different causes that may produce chronic liver disease. And hypergammaglobulinemiawas detected in liver biopsy: interface hepatitis, mixed inflammatory infiltrate with predominance of lymphocytes, and presence of portal-portal fibrous tracts, suggestive of severe active chronic hepatitis may be secondary to autoimmune hepatitis associated with hepatitis virus infection E. With these findings, we decided to start treatment for autoimmune hepatitis with prednisone and azathioprine, leading to a decrease in transaminases and coagulation profile to normal, which helped confirm the diagnosis of autoimmune hepatitis and decompesated manifested by acute virus infection of hepatitis E. Full report the case and a review of the literature.

Evaluation of diamond coatings on optical fibre sensors for biological use.

The inscription of a Fibre Bragg Grating (FBG) in optical fibres allows them to be used as sensors, being capable of decoding small variations of strain; temperature; pressure; loading; bending; or even refractive index, by means of a shift in the reflected wavelength. Nevertheless, broadening their sensitivity and operation range would be desirable. This may be achieved by appropriated fibre coating. Diamond possesses a set of extreme properties, such as high thermal conductivity, hardness and resistance to hazard environments. Furthermore, it is known for its excellent biocompatible response, so it may be suitable to be used as a coating material for biological sensors. In this paper, the results of the optimization process of diamond coatings on optical fibre sensors is presented, considering their potential use for practical biological purposes.

[Esomeprazole based triple therapy for the eradication of helicobacter pylori in patients with non-ulcer dyspepsia]. / Esomeprazol en la terapia triple para la erradicacion de helicobacter pylori en pacientes dispepticos no ulcerosos.

OBJECTIVE: To assess the efficacy of esomeprazole-based triple therapy in the eradication of helicobacter pylori (HP). METHODOLOGY: A descriptive, prospective study was carried out between the months of June and August, 2008, at the Gastroenterology Service of the Cayetano Heredia National Hospital (HNCH) in which patients with non-ulcer dyspepsia infected with HP (diagnosed bya biopsy) were randomized and divided into two groups: the control group was treated with Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Omeprazole (20 mg VO e/12h) and the study group received Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Esomeprazole (20 mg VO e/12h); both treatments were administered over a period of ten days. Four weeks after the conclusion of the treatment, each group underwent an endoscopic control, including biopsy tests and breath tests to determine the eradication of the HP infection. RESULTS: A total of 83 patients were included, out of which 42 received triple therapy with Omeprazole (control group) and 41 received triple therapy with Esomeprazole (study group). Five patients of the control group and 7 of the study group were lost in the follow-up stage and 3 patients of the control group and 2 of the study group were excluded due to the lack of a breath test. Out of the 34 patients of the control group, HP was eradicated in 25 of them (73,5%) while out of the 32 patients of the study group, HP was eradicated in 26 (81,2%). The most important adverse effects included: diarrhea, headaches, abdominal pain and constipation. CONCLUSIONS: Treatment with Esomeprazole showed an eradication rate of 8% greater than treatment with Omeprazole and the percentage of adverse effects was similar in both groups.

Esomeprazol en la terapia triple para la erradicación de Helicobacter Pylori en pacientes dispépticos no ulcerosos / Esomeprazole based triple therapy for the eradication of Helicobacter Pylori in patients with non-ulcer dyspepsia

OBJETIVO: El presente trabajo tiene como objetivo principal, evaluar la eficacia de la terapia triple con esomeprazol en la erradicación del Helicobacter pylori (Hp). METODOLOGÍA: Se realizó un estudio descriptivo, prospectivo en el Servicio de gastroenterología del Hospital Nacional Cayetano Heredia (HNCH), donde se seleccionaron pacientes dispépticos no ulcerosos con infección por Hp (determinada mediante biopsia) entre los meses de junio a agosto del 2008, a los cuales se les dividió en dos grupos: el ¨grupo control¨ se trató conamoxicilina 1g VO c/12h, claritromicina 500 mg VO c/12h y omeprazol 20 mg VO c/12h, y el ¨grupo en estudio¨ recibió amoxicilina 1g VO c/12h, claritromicina 500 mg VO c/12h y esomeprazol 20 mg VO c/12h, ambos esquemas se dieron por 10 días. A las 4 semanas de completado el tratamiento, a cada grupo se le hizo un control endoscópico con toma de biopsias y test de aliento para determinar la erradicación del Hp. RESULTADOS: Se incluyó un total de 83 pacientes, de los cuales 42 recibieron terapia triple con omeprazol (grupo control) y 41 recibieron terapia triple con esomeprazol (grupo en estudio). Se perdieron en el seguimiento 5 pacientes del grupo control y 7 pacientes en el grupo en estudio. Por no contar con Test de aliento se excluyeron 3 pacientes en el grupo control y 2 pacientes en el grupo en estudio. De los 34 pacientes del grupo control se erradicó el Hp en 25 (73,5%), mientras que los 32 pacientes del grupo en estudio se erradicó el Hp en 26 (81,2%). Los efectos adversos más importantes incluyeron: diarrea, cefalea, dolor abdominal y estreñimiento. CONCLUSIONES: El tratamiento con esomeprazol presentó una tasa de erradicación 8% mayor que el esquema con omeprazol y el porcentaje de reacciones adversas fue similar enambos grupos.

OBJECTIVE: To assess the efficacy of esomeprazole-based triple therapy in the eradication of helicobacter pylori (HP). METHODOLOGY: A descriptive, prospective study was carried out between the months of June and August, 2008, at the Gastroenterology Service of the Cayetano Heredia National Hospital (HNCH) in which patients with non-ulcer dyspepsia infected with HP (diagnosed by a biopsy) were randomized and divided into two groups: the "control group" was treated with Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Omeprazole (20 mg VO e/12h) and the "study group" received Amoxicillin (1g VO e/12h), Clarithromycin (500 mg VO e/12h) and Esomeprazole (20 mg VO e/12h); both treatments were administered over a period of ten days. Four weeks after the conclusion of the treatment, each group underwent an endoscopic control, including biopsy tests and breath tests to determine the eradication of the HP infection. RESULTS: A total of 83 patients were included, out of which 42 received triple therapy with Omeprazole (control group) and 41 received triple therapy with Esomeprazole (study group). Five patients of the control group and 7 of the study group were lost in the follow-up stage and 3 patients of the control group and 2 of the study group were excluded due to the lackof a breath test. Out of the 34 patients of the control group, HP was eradicated in 25 of them (73,5%) while out of the 32 patients of the study group, HP was eradicated in 26 (81,2%). The most important adverse effects included: diarrhea, headaches, abdominal pain and constipation. CONCLUSIONS: Treatment with Esomeprazole showed an eradication rate of 8% greater than treatment with Omeprazole and the percentage of adverse effects was similar in both groups.

Wide social participation in prioritizing patients on waiting lists for joint replacement: a conjoint analysis.

OBJECTIVE: The aim was to develop a priority scoring system for patients on waiting lists for joint replacement based on a wide social participation, and to analyze the differences among participants. METHODS: Conjoint analysis. Focus groups in combination with a nominal technique were employed to identify the priority criteria (N=36). A rank-ordered logit model was then applied for scoring estimations. Participants (N=860) represented: consultants, allied-health professionals, patients and their relatives, and the general population of Catalonia. RESULTS: Clinical and social criteria were selected, and their relative importance (over 100 points) was: pain (33), difficulty in doing activities of daily living (21), disease severity (18), limitations on ability to work (10), having someone to look after the patient (9), being a caregiver (6), and recovery probability (4). Estimated criteria coefficients had the expected positive sign and all were statistically significant (P < 0.001). There were differences between groups; pain was rated higher by patients/relatives, and difficulty in doing activities was rated lower by patients/relatives and the general public. Most interaction terms for these criteria and groups were significant (P < 0.001). Consultants and allied-health professionals had the most similar prioritization pattern (r=0.97). CONCLUSION: Both clinical and social criteria are considered for prioritization of joint replacement surgery from a wide social perspective. The preference among professional and social groups varies and this might impact the result of patient prioritization. A wide social participation for obtaining adequate prioritizing systems for patients on waiting lists is desirable.

[Choledochal cyst in pregnancy and puerperium: report on two cases and review of literature]. / Quiste de colédoco en la gestación y puerperio: reporte de dos casos y revisión de la literatura.

A choledochal cyst is a cystic dilation of the intrahepatic or extrahepatic biliary tract. According to the most accepted theory, it is caused by an anomalous pancreatobiliary junction. The most important complications are cholangiocarcinoma, lithiasis, and pancreatitis. Current therapy is surgical resection. Only 20% to 30% of cases are diagnosed in adult life. Two cases of choledochal cysts are reported in female adult patients, one of them in late pregnancy and the other in puerperium. Diagnosis of choledochal cyst in pregnancy and puerperium is an uncommon event, entailing particular considerations regarding symptoms and treatment.

Errores medicos en el mejoramiento continuo de la calidad / Medical errors in the continuous improvement of quality

The increase in medical errors during the last four decades of past centuries can be attributed to several causes: the human fallibility always present, concern in quality and continuity of physician-patient relationship and to the increased advance in technology innovation. These errors attract the attention of Agencies and Organizations involved in Healthcare Quality. From the work of these a series of recommendations were issued for the prevention of medical errors. The action level is a systemic one, due to the characteristic of the healthcare services

[What is an efficient health technology in Spain?]. / Qué es una tecnología sanitaria eficiente en España?

INTRODUCTION: Despite the growing recognition of the potential applications of cost-effectiveness assessments, a criterion to establish what is an efficient health technology does not exist in Spain. The objective of this work is to describe the limits and the criteria used in Spain to recommend the adoption of health interventions. METHOD: A review of the economic evaluations of health technologies published in Spain from 1990 to 2001 was conducted. Complete economic assessments in which the cost-effectiveness ratio was expressed as cost per life-year gained (LYG), cost per quality-adjusted-life-year (QALY) or cost per saved live were selected. Those interventions in which the authors established recommendations (adoption or rejection) and the criteria used were analyzed. RESULTS: Twenty (20%) of the 100 complete economic evaluations fulfilled the selection criteria. In16 studies, the results were expressed as cost per LYG, in 6 studies as cost per QALY and in 1 as cost per saved live. A total of 82 health interventions were assessed and some kind of recommendation was established in 44 of them. All technologies with a cost-effectiveness ratio lower than 30,000 euros (5 million pesetas) per LYG were recommended for adoption by the authors. Up to that limit there was no a clear tendency. CONCLUSIONS: Although the results must be interpreted with much precaution, given the limitations of the study, the limits of cost-effectiveness presented in this work could be a first reference to which would be an efficient health intervention in Spain.

The social value of health programmes: is age a relevant factor?

In cost-effectiveness analysis (CEA) it is usually assumed that a quality-adjusted life-year (QALY) is of equal value to everybody, irrespective of the patient's age. However, it is possible that society assigns different social values to a QALY, according to who gets it. In this paper, we discuss the possibility of weighting health benefits for age in CEA. We also examine the possibility that age-related preferences depend on the size of the health gain. An experiment was performed to test these hypotheses. The assessment of results suggests that the patient's age is a relevant factor when assessing health gains.

[Cost effectiveness analysis of highly active antiretroviral therapy in HIV asymptomatic patients]. / Análisis coste-efectividad del tratamiento antirretroviral de gran actividad en pacientes infectados por el VIH asintomáticos.

BACKGROUND: Assessment of cost and effectiveness in highly active antiretroviral therapy (HAART) in HIV asymptomatic patients. PATIENTS AND METHODS: A cohort of several asymptomatic HIV-infected patients were observed under real practice and treated with two nucleosid analogues (AN) of which therapy was modified. A protease inhibitor (PI) was added and at least one AN was changed (or not), following the current clinical recommendations (1997). Data on direct cost (drug cost, visits and clinical procedures) were then recorded both three and six months after the beginning of the study. Data on effectiveness (percentage of patients with undetectable levels of viral load) and quality of life were next measured according to the EuroQol, and recorded at the same time. All patients used a monthly diary to keep record of resource consumption and quality of life progress. RESULTS: All treatment regimens were effective in lowering the viral load and improve quality of life. The less expensive HAART was AZT + 3TC + IND (1,037,757 pesetas) and AZT + ddl + IND (1,045,339 pesetas), but both were the least effective to reduce patient's viral load to undetectable levels (52.7 and 57.7% respectively); meanwhile d4T + 3TC + IND (1,188,177 pesetas) and d4T + ddl + IND (1,212,285 pesetas) were more expensive but more effective (67.9 and 66% respectively). Cost-effectiveness ratios ranged between 9,896 and 13,122 pesetas. There was no statistically significant differences in quality of life among the different HAART regimens. CONCLUSIONS: HAART implementation is effective in reducing patients' viral load to undetectable levels and to slightly improve their quality of life after six months. Costs and effectiveness vary according to the type of HAART treatment used.

[Effectiveness and cost of total hip replacement in seven hospitals in Catalonia, Spain]. / Efectividad y costes de la intervención de prótesis total de cadera en siete hospitales de Cataluña.

BACKGROUND: To quantify short-term benefits of total hip replacement, prognostic factors of the outcome, and to assess hospital costs of this surgical procedure in Catalonia, Spain. PATIENTS AND METHODS: Multicentric prospective study in seven hospitals in Catalonia. All patients undergoing this procedure in one year were included. They were evaluated prior to the operation, and six months later. This evaluation involved: clinical assessment, the Hip Pain and Function Scale, the Nottingham Health Profile (NHP), and the EuroQol (EQ-5D), in order to measure cost-utility. Hospital costs were estimated by means of a specific questionnaire. RESULTS: Information was obtained for 332 patients. The mean age was 65 years (range: 27-89 years); 58% were women; the most common diagnosis was arthritis; 59% of patients had associated pathology and 13% presented some type of postoperative complication. The improvement in health status was important according to all instruments. An outcome of "excellent" or "good" was achieved by 70.8% of the patients, in terms of hip function and pain. The factors associated with not achieving an outcome of this level were: associated pathology, complications, diagnoses other than arthritis, and operation carried out in a tertiary hospital. The total cost of the procedure was 838,480 pesetas. This average varied significantly with the cost of the prosthesis, and as a function of the length of stay. The three-year cost-utility of the procedure was estimated as 507,500 pesetas. CONCLUSIONS: Total hip replacement greatly improves the pain, hip function and overall perceived health of the patient. This improvement is greater among patients with a diagnosis of arthritis, with good overall health, operated on by a surgeon experienced in this procedure. The benefit is high in relation to the cost, although there is a margin for improvement, reducing complications, shortening length of stay, and controlling the price of implants.

KID syndrome associated with features of ichthyosis hystrix.

Keratitis-ichthyosis-deafness (KID) syndrome is a congenital ectodermal disorder causing erythrokeratoderma, vascularizing keratitis, and neurosensory deafness. Ichthyosis hystrix is a rare cutaneous disease characterized by well-demarcated, spiky, verrucous, linear plaques that is believed to be a clinical and pathologic chimera of two autosomal dominant diseases: epidermal nevus and epidermolytic hyperkeratosis. We present a patient with the classic triad of KID syndrome with clinical and histologic features of ichthyosis hystrix. This case demonstrates that KID syndrome comprises a spectrum of ectodermal disorders which may include diseases such as hystrix ichthyosis and deafness (HID) syndrome.

Incorporating societal concerns for fairness in numerical valuations of health programmes.

The paper addresses some limitations of the QALY approach and outlines a valuation procedure that may overcome these limitations. In particular, we focus on the following issues: the distinction between assessing individual utility and assessing societal value of health care; the need to incorporate concerns for severity of illness as an independent factor in a numerical model of societal valuations of health outcomes; similarly, the need to incorporate reluctance to discriminate against patients that happen to have lesser potentials for health than others; and finally, the need to combine measurements of health-related quality of life obtained from actual patients (or former patients) with measurements of distributive preferences in the general population when estimating societal value. We show how equity weights may serve to incorporate concerns for severity and potentials for health in QALY calculations. We also suggest that for chronically ill or disabled people a life year gained should count as one and no less than one as long as the year is considered preferable to being dead by the person concerned. We call our approach 'cost-value analysis'.

Quantitative analysis of smooth muscle fibers in corpus cavernosum of human fetuses.

PURPOSE: Quantify objectively the normative distribution and the percentage of smooth muscle fibers in the corpus cavernosum of human fetuses with 24 weeks post-conception (WPC) of gestational age. MATERIAL AND METHODS: We studied 7 penises taken from 7 fresh human fetuses. We analyzed 5 randomized sections from each penis and in every section we analyzed 3 fields, totaling 15 fields per penis and 105 fields for the final results. Immunohistological staining for the smooth muscle fibers was used to accentuate the differences between the intracavernous structures (smooth muscle fibers and collagen fibers). The fields studied were digitized with a final magnification of 450X and a computerized analysis of the smooth muscle fibers was performed with image analyzer software. The percentage of smooth muscle fibers per standard square area was estimated and the mean value was used for each penis. RESULTS: The distribution of smooth muscle fibers in the corpus cavernosum of human fetuses with 24 WPC of gestational age ranged from 17.52% to 27.76% of the total area. The mean value was 22.72% and the standard deviation was 3.56. CONCLUSIONS: Our results show that the percentage of smooth muscle cells in corpus cavernosum of human fetuses with 24 WPC of gestational age is significantly smaller when compared with the data available for adult cadavers.

Primary invasive carcinoma of the vagina.

A retrospective study of 29 patients with invasive carcinoma of the vagina was completed at The Milton S. Hershey Medical Center, Pennsylvania State University, for a ten-year period from 1976-1986. The overall incidence was 1.3% of all gynecologic malignancies. Twenty-four patients (83%) had squamous cell carcinoma and five (17%) had adenocarcinoma. Squamous cell carcinoma was most commonly located in the upper anterior and lateral vaginal vaults, whereas adenocarcinoma was found more often in the lower anterior and lateral vaginal vaults. The majority of the patients (96%) were managed by a combination of whole-pelvis irradiation and brachytherapy. Twenty-four percent of the patients had a recurrence in the vagina only, indicating the need for better local control. The overall survival rate was 48%. Patients with previous hysterectomy were more likely to develop serious treatment-related complications.

Relatório sobre 72 casos de apresentações cefálicas defletidas, ocorridas no serviço de obstretricia da casa Maternal e da Infância "Leonor Mendes de Barros"

O presente trabalho, baseado em dados estatísticos obtidos sobre 20.196 partos ocorridos na casa Matenal e da Infância, de Agosto de 1944 a Março de 1949, tem por fim apreciar a importância da apresentação cefálica defletida como problema obstétrico em nosso meio(AU)