Development and Underlying Structure of a Second-Generation Appropriateness Classification System for Total Knee Arthroplasty.

OBJECTIVE: Evidence supports the validity of total knee arthroplasty (TKA) appropriateness classification based on the RAND Corporation and University of California Los Angeles system.The system, however, is ~2 decades old, and the science and clinical application of TKA has changed dramatically. We undertook this study to describe the methods used to develop a second-generation system and to examine the structure of the system to determine the extent to which each of the indication criteria informed appropriateness. METHODS: Multivariable multinomial regression analyses determined the extent to which each of the 8 individually analyzed indication criteria informed appropriateness judgments. Classification tree analysis illustrates how the indication criteria, in combination, led to judgments of appropriate, inappropriate, or uncertain. RESULTS: An expert panel selected 8 indication criteria (i.e., age, knee pain, function, radiographic osteoarthritis severity, osteoarthritis location, psychological factors, pain catastrophizing, and comorbidities). A total of 1,008 clinical scenarios were written, based on the criteria. Regression analyses indicated that age, knee pain, function, and radiographic severity dominated prediction of appropriateness, while the other criteria played a smaller role. Classification tree analysis confirmed the regression findings. CONCLUSION: Our second-generation classification system, which incorporates contemporary indicators of TKA prognosis and risk, demonstrated preliminary evidence for utility in clinical practice.

Cost-effectiveness analysis of a surveillance program to prevent hip dislocation in children with cerebral palsy / Análisis de coste-utilidad de un programa de vigilancia para prevenir la luxación de cadera en niños y niñas con parálisis cerebral

OBJECTIVE: In this study we conducted an economic evaluation of a surveillance programme to prevent hip dislocation in children with cerebral palsy. METHOD: We developed a model that compared costs and health outcomes of children with cerebral palsy with and without a surveillance programme. Information from a number of sources was combined into a decision analytical model, primarily based on data from a comparative study with a 20-year follow-up. Effectiveness was measured using Quality-Adjusted Life Years (QALYs). The analysis took the perspective of the Spanish National Health Service. We undertook extensive sensitivity analyses including a probabilistic sensitivity analysis. RESULTS: The surveillance programme led to higher QALYs and higher health care costs, with an estimated incremental cost per QALY gained of 12,282€. The results were robust to model assumptions. The probability that the programme was cost-effective was estimated to be over 80% at the threshold of 25.000€/QALY recommended in Spain. CONCLUSION: This study indicates that surveillance programmes to prevent hip dislocation in children with cerebral palsy are likely to be cost-effective

OBJETIVO: En este estudio se realiza una evaluación económica de un programa de vigilancia para prevenir la luxación de cadera en niños y niñas con parálisis cerebral. MÉTODO: Se desarrolló un modelo que comparó los costes y los resultados en salud de niños y niñas con parálisis cerebral incluidas y no incluidas en un programa de vigilancia. Se combinó la información proveniente de diversas fuentes en un modelo analítico de decisión, principalmente basado en datos de un estudio comparativo con 20 años de seguimiento. La efectividad se midió empleando los años de vida ajustados por calidad (AVAC). El análisis tomó la perspectiva del Sistema Nacional de Salud de España. Se realizó un extenso análisis de sensibilidad, incluyendo un análisis de sensibilidad probabilístico. RESULTADOS: El programa de vigilancia estuvo asociado a más AVAC y mayores costes sanitarios, con un coste incremental por AVAC ganado estimado en 12.282 €. Los resultados fueron robustos a los supuestos del modelo. La probabilidad de que el programa fuera coste-efectivo se estimó en un valor por encima del 80% para el umbral de 25.000 € por AVAC recomendado en España. CONCLUSIÓN: Este estudio indica que es probable que los programas de vigilancia para prevenir la luxación de cadera en niños y niñas con parálisis cerebral sean coste-efectivos

Cost-effectiveness analysis of a surveillance program to prevent hip dislocation in children with cerebral palsy.

OBJECTIVE: In this study we conducted an economic evaluation of a surveillance programme to prevent hip dislocation in children with cerebral palsy. METHOD: We developed a model that compared costs and health outcomes of children with cerebral palsy with and without a surveillance programme. Information from a number of sources was combined into a decision analytical model, primarily based on data from a comparative study with a 20-year follow-up. Effectiveness was measured using Quality-Adjusted Life Years (QALYs). The analysis took the perspective of the Spanish National Health Service. We undertook extensive sensitivity analyses including a probabilistic sensitivity analysis. RESULTS: The surveillance programme led to higher QALYs and higher health care costs, with an estimated incremental cost per QALY gained of 12,282€. The results were robust to model assumptions. The probability that the programme was cost-effective was estimated to be over 80% at the threshold of 25.000€/QALY recommended in Spain. CONCLUSION: This study indicates that surveillance programmes to prevent hip dislocation in children with cerebral palsy are likely to be cost-effective.

Valoración del riesgo de caries infantil en un servicio hospitalario de urgencias / Risk assessment for childhood caries in a hospital emergency department

La caries es una destrucción de los tejidos mineralizados del diente, siendo la enfermedad crónica más prevalente del niño. Objetivos: Determinar, mediante un estudio de enfermería, la prevalencia de riesgo de caries en los niños que acuden a un Servicio de Urgencias Hospitalarias. Método: Aplicación del formulario validado para la evaluación de riesgo de caries propuesto por la Sociedad Americana de Odontopediatría, con 14 ítems para niños de más de 7 años y 13 ítems en menores de esa edad. La aplicación de dicho formulario ha contemplado la caducidad de la dentición temporal en relación a la edad del niño estudiado. Resultados: El formulario se ha completado en 101 niños. El 72.7% de los niños menores de 7 años y el 89.1% de los mayores de 7 años presentan uno o más factores de alto riesgo para caries infantil, existiendo diferencias notables en los resultados, en función del origen de los niños o de su etnia. Los peores resultados los ofrecen los niños gitanos cuyo riesgo de caries es el 100% en grupos de cualquier edad. Conclusiones: Hemos determinado mediante un estudio de enfermería, la prevalencia de riesgo de caries infantil. La Enfermería española puede y debe asumir un papel activo en la promoción de la salud oral infantil, aplicando activamente sus conocimientos (AU)

Dental caries is a destruction of the mineralized tissues of the tooth and is the most prevalent chronic disease of children. Objective: Determine, by a nurse study, the prevalence of high risk of dental caries among children treated at a hospital emergency room. Methods: We applied an adaptation of the form CAT (caries-risk assessment tool) proposed by the American Society of Pediatric Dentistry, consisting of 14 items for children over 7 years and 13 items for children under that age. The test has been applied considering the resorption time of the deciduous teeth in relation to the child's age studied. Results: The form has been completed in 101 children. 72.7% of children under 7 years old and 89.1% of those aged 7 years have one or more high risk factors for childhood caries. We found differences in the results, depending on the origin or ethnicity of the children studied. Conclusions: We determined the prevalence of risk for childhood caries. The Spanish nurses can and should play an active role in promoting children's oral health, actively applying their knowledge (AU)

Modelling the relationship between the WOMAC Osteoarthritis Index and EQ-5D.

OBJECTIVE: Economic evaluation typically is conducted using health state utilities to estimate treatment benefits. However, such outcomes are often missing from studies of clinical effectiveness. This study aims to bridge that gap by providing appropriate methods to link values from the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to the EQ-5D utility instrument. METHOD: Patients from a large registry of Spanish patients (n = 7072 observations) with knee or hip osteoarthritis who completed both WOMAC and EQ-5D was used. A mixture model approach was used based on distributions bespoke to the EQ-5D UK value set to estimate EQ-5D as a function of WOMAC pain, stiffness and function subscores. RESULTS: A five class mixture model provides very close fit to the observed data at all levels of disease severity. The overall mean (0.542 vs 0.542), median (0.620 vs 0.636) and the percentage of observations at full health (15 vs 14.8) were very similar between the observed data and the estimated model respectively. Stiffness has limited relationship to EQ-5D, whereas functional disability and pain are strong predictors. CONCLUSION: EQ-5D can be reliably estimated from WOMAC subscale scores without any systematic bias using these results.

Hiperparatiroidismo primario y crisis hipercalcémica aguda tóxica / Primary hyperparathyroidism and acute toxic hypercalcaemic crisis

Objetivos: Describir las características clínicas y tratamiento quirúrgico de los pacientes con hipercalcemia aguda por hiperparatiroidismo primario (HPTP) y compararlas con las de otros pacientes con HPTP sin hipercalcemia aguda asociada. Material y métodos Estudio observacional prospectivo (1998-2010) sobre 158 pacientes con HPTP tratados mediante paratiroidectomía. Se identificaron aquellos con hipercalcemia aguda (>14mg/dl-3,5mmol/l- o >3mmol/l con síntomas de calciotoxicosis), se evaluaron sus características clínicas y terapéuticas y se compararon, mediante la U de Mann-Whitney y el test de Fisher, con los 146 pacientes con HPTP sin crisis hipercalcémicas. Resultados Doce pacientes (7,6%) presentaron hipercalcemia aguda con síntomas de calciotoxicosis y otros síntomas de cronicidad. Los valores preoperatorios de calcemia y PTH fueron 14,5±1,3mg/dl y 648,2±542pg/dl, respectivamente. Hubo 10 adenomas, una hiperplasia y un carcinoma. El peso medio de las piezas quirúrgicas fue 4.075±2.918 mg con un diámetro mayor de 27±14mm. Los gradientes de caída de PTH a los 10 y 25min fueron 79±18% y 92±6%. Las calcemias postoperatorias al alta y a los 6 meses fueron 8,2±0,7 y 9,1±0,9mg/dl. Las concentraciones plasmáticas de Ca, PTH y el peso y tamaño de las piezas quirúrgicas fueron mayores en los pacientes con crisis hipercalcémicas (p<0,001). No hubo diferencias en otros parámetros estudiados y en la tasa de curación. Conclusiones Las crisis hipercalcémicas fueron producidas por tumores más grandes, de mayor peso y que producían mayores concentraciones plasmáticas de Ca y PTH. Todos los pacientes presentaban síntomas de evolución crónica y la paratiroidectomía consiguió la curación (AU)

Objectives: To describe the clinical characteristics and surgical treatment of patients with acute hypercalcaemia due to primary hyperparathyroidism (PHPT) and compare them with other patients with PHPT without associated acute hypercalcaemia. Material and methods: A prospective, observational study (1998-2010) was conducted on 158patients with PHPT treated by parathyroidectomy. Those with acute hypercalcaemia(>14 mg/dl -3.5 mmol/L- or >3 mmol/L with symptoms of calcium toxicity) were evaluated by recording their clinical and treatment characteristics, and comparing them, using the Mann-Whitney U test and the Fisher test, with the 146 PHPT patients without hypercalcaemic crisis. Results: Twelve patients (7.6%) had acute hypercalcaemia with symptoms of calcium toxicity and other symptoms of chronicity. The preoperative calcium and PTH values were14.5 1.3 mg/dL and 648.2 542 pg/dL, respectively. There were 10 adenomas, 1 hyperplasia and 1 carcinoma. The mean weight of the surgical pieces was 4.075 2.918 mg, with a diameter greater than 27 14 mm. The gradients of PTH at 10 and 25 minutes were 79 18%and 92 6%, respectively. Post-operative calcium values on discharge and at 6 months were8.2 0.7 mg/dL and 9.1 0.9 mg/dL, respectively. The plasma concentrations of calcium, PTH, and the size of the surgical pieces were higher in patients with hypercalcaemic crisis(P<0.001). There were no differences in the other parameters studied or in the cure rate. Conclusions: Hypercalcaemic crises were caused by larger and heavier tumours that led to higher plasma Ca and PTH plasma concentrations. All patients had long-standing symptoms and parathyroidectomy led to cure of the disease (AU)

[Primary hyperparathyroidism and acute toxic hypercalcaemic crisis]. / Hiperparatiroidismo primario y crisis hipercalcémica aguda tóxica.

OBJECTIVES: To describe the clinical characteristics and surgical treatment of patients with acute hypercalcaemia due to primary hyperparathyroidism (PHPT) and compare them with other patients with PHPT without associated acute hypercalcaemia. MATERIAL AND METHODS: A prospective, observational study (1998-2010) was conducted on 158 patients with PHPT treated by parathyroidectomy. Those with acute hypercalcaemia (>14 mg/dl -3.5 mmol/L- or >3 mmol/L with symptoms of calcium toxicity) were evaluated by recording their clinical and treatment characteristics, and comparing them, using the Mann-Whitney U test and the Fisher test, with the 146 PHPT patients without hypercalcaemic crisis. RESULTS: Twelve patients (7.6%) had acute hypercalcaemia with symptoms of calcium toxicity and other symptoms of chronicity. The preoperative calcium and PTH values were 14.5 ± 1.3mg/dL and 648.2 ± 542 pg/dL, respectively. There were 10 adenomas, 1 hyperplasia and 1 carcinoma. The mean weight of the surgical pieces was 4.075 ± 2.918 mg, with a diameter greater than 27 ± 14 mm. The gradients of PTH at 10 and 25 minutes were 79 ± 18% and 92 ± 6%, respectively. Post-operative calcium values on discharge and at 6 months were 8.2 ± 0.7 mg/dL and 9.1 ± 0.9 mg/dL, respectively. The plasma concentrations of calcium, PTH, and the size of the surgical pieces were higher in patients with hypercalcaemic crisis (P<0.001). There were no differences in the other parameters studied or in the cure rate. CONCLUSIONS: Hypercalcaemic crises were caused by larger and heavier tumours that led to higher plasma Ca and PTH plasma concentrations. All patients had long-standing symptoms and parathyroidectomy led to cure of the disease.

[Prevalence of main cardiovascular risk factors in women from Biscay]. / Prevalencia de los principales factores de riesgo cardiovascular en mujeres de Vizcaya.

INTRODUCTION AND OBJECTIVES: The aim of this study was to analyze the prevalence of principal cardiovascular risk factors in the female population from Biscay (northern Spain). PATIENTS AND METHOD: We selected a random representative sample of 1,317 women aged between 16 and 65 years from this province. For each participant we recorded the following parameters: weight and height, physical activity, smoking, blood pressure, glycemia, total cholesterol, triglycerides, HDL-cholesterol and LDL-cholesterol. RESULTS: A total of 1,100 women (mean age 39.83 14 years) participated. Regarding physical activity, 31.9% of the women had a sedentary lifestyle and 48.4% did not exercise during leisure time. The prevalence of smoking was 31.9%. We found a mean body mass index of 24.9 4.6 kg/m2, and 42.4% of the women were overweight. The prevalence of hypertension was 13.1%, hypertension being defined as a mean systolic blood pressure > or = 160 mmHg, diastolic blood pressure > or = 95 mmHg, current antihypertensive treatment, or any combination of these criteria. When a cutoff value of > or = 140/90 mmHg was used, the prevalence increased to 26.7%. Total cholesterol values were > or = 240 mg/dl in 26.2%, triglyceride levels were > or = 200 mg/dl in 2.6%, LDL-cholesterol was > or = 160 mg/dl in 26.8%, and HDL-cholesterol values were < 45 mg/dl in 12.2%. The prevalence of hyperglycemia was 3.3%. CONCLUSIONS: The prevalences of main cardiovascular risk factors were similar to those in other Spanish studies. Except for smoking, the rest of these risk factors increased with age. Long-term measures should be adopted to modify dietary habits and lifestyles to obtain improvements in the cardiovascular risk profile.

Prevalencia de los principales factores de riesgo cardiovascular en mujeres de Vizcaya / Prevalence of main cardiovascular risk factors in women from Biscay

Introducción y objetivos. Analizar la prevalencia de los principales factores de riesgo cardiovascular en mujeres de Vizcaya. Pacientes y método. Seleccionamos una muestra de 1.317 mujeres con edades comprendidas entre 16-65 años, ambas inclusive, representativa de la población femenina de Vizcaya. Se determinaron el peso y la talla, la actividad física, el hábito tabáquico, la presión arterial, la glucemia, el colesterol total, los triglicéridos, y el colesterol unido a lipoproteínas de alta densidad (cHDL) y de baja densidad (cLDL).Todas las pruebas se realizaron durante el año 1993. Resultados. Acudieron al estudio 1.100 mujeres, con una edad media de 39,83 ñ14 años. El 31,9 por ciento de las mujeres realizaban una actividad habitual sedentaria y el 48,4 por ciento no hacían ningún ejercicio físico en el tiempo libre.La prevalencia de consumo de tabaco fue del 31,9 por ciento. El valor medio del índice de masa corporal (IMC) se estableció en 24,9 ñ 4,6 kg/m2 y el 42,4 por ciento de las mujeres tenían un exceso de peso. La prevalencia de hipertensión arterial fue del 13,1 por ciento, porcentaje en el que se incluyó a las mujeres con una presión arterial sistólica (PAS) 160 mmHg y/o diastólica (PAD) 95 mmHg o que estuvieran tomando medicación antihipertensiva. Al considerar unos valores de PAS y PAD 140/90 mmHg, la prevalencia ascendió al 26,7 por ciento. El 26,2 por ciento presentó valores de colesterol total 240 mg/dl; el 2,6 por ciento triglicéridos 200 mg/dl; el 26,8 por ciento cLDL 160 mg/dl y el 12,2 por ciento cHDL < 45 mg/dl. La prevalencia de hiperglucemia fue del 3,3 por ciento. Conclusiones. La prevalencia de factores de riesgo es similar a la obtenida en otros estudios españoles y se ha observado que todos ellos, excepto el tabaquismo, aumentan con la edad. Consideramos necesario adoptar medidas encaminadas a modificar a largo plazo los hábitos dietéticos y los estilos de vida, para conseguir una mejora del perfil de riesgo cardiovascular (AU)