Reverse total shoulder arthroplasty with proximal bone loss: a biomechanical comparison of partially vs. fully cemented humeral stems.

BACKGROUND: The appropriate amount of cementation at the time of reverse total shoulder arthroplasty with significant proximal bone loss or resection is unknown. Extensive cementation of a humeral prosthesis makes eventual revision arthroplasty more challenging, increasing the risk of periprosthetic fracture. We analyzed the degree of subsidence and torque tolerance of humeral components undergoing standard cementation technique vs. our reduced polymethyl methacrylate (PMMA) protocol. Reduced cementation may provide sufficient biomechanical stability to resist physiologically relevant loads, while still permitting a clinically attainable torque for debonding the prosthesis. METHODS: A total of 12 cadaveric humeri (6 matched pairs) underwent resection of 5 cm of bone distal to the greater tuberosity. Each pair of humeri underwent standard humeral arthroplasty preparation followed by either cementation using a 1.5-cm PMMA sphere at a location 3 cm inferior to the porous coating or standard full stem cementation. A 6-degree-of-freedom robot was used to perform all testing. Each humeral sample underwent 200 cycles of abduction, adduction, and forward elevation while being subjected to a physiologic compression force. Next, the samples were fixed in place and subjected to an increasing torque until implant-cement separation or failure occurred. Paired t tests were used to compare mean implant subsidence vs. a predetermined 5-mm threshold, as well as removal torque in matched samples. RESULTS: Fully and partially cemented implants subsided 0.49 mm (95% CI 0.23-0.76 mm) and 1.85 mm (95% CI 0.41-3.29 mm), respectively, which were significantly less than the predetermined 5-mm threshold (P < .001 and P < .01, respectively). Removal torque between fully cemented stems was 45.22 Nm (95% CI 21.86-68.57 Nm), vs. 9.26 Nm (95% CI 2.59-15.93 Nm) for partially cemented samples (P = .021). Every fully cemented humerus fractured during implant removal vs. only 1 in the reduced-cementation group. The mean donor age in our study was 76 years (range, 65-80 years). Only 1 matched pair of humeri belonged to a female donor with comorbid osteoporosis. The fractured humerus in the partially cemented group belonged to that donor. CONCLUSION: Partially and fully cemented humeral prostheses had subsidence that was significantly less than 5 mm. Partially cemented stems required less removal torque for debonding of the component from the cement mantle. In all cases, removal of fully cemented stems resulted in humeral fracture. Reduced cementation of humeral prostheses may provide both sufficient biomechanical stability and ease of future component removal.

Full Reversal of Anticoagulants Before Cephalomedullary Fixation of Geriatric Hip Fractures May Not Be Necessary.

OBJECTIVES: To examine the relationship between anticoagulant and antiplatelet drugs and surgical blood loss for geriatric patients undergoing cephalomedullary nail fixation of extracapsular proximal femur fractures. DESIGN: Multicenter, retrospective, cohort study using bivariate and multivariable regression analyses. SETTING: Two Level-1 trauma centers. PATIENTS: One thousand four hundred forty-two geriatric (ages 60-105 years) patients undergoing isolated primary intramedullary fixation of nonpathologic extracapsular hip fractures from 2009 to 2018 including 657 taking an antiplatelet drug alone (including aspirin), 99 taking warfarin alone, 37 taking a direct oral anticoagulant (DOAC) alone, 59 taking an antiplatelet drug and an anticoagulant, and 590 taking neither. INTERVENTION: Cephalomedullary nail fixation. MAIN OUTCOME MEASUREMENTS: Blood transfusion and calculated blood loss. RESULTS: More patients taking antiplatelet drugs required a transfusion than controls (43% vs. 33%, P < 0.001), whereas patients taking warfarin or DOACs did not (35% or 32% vs. 33%). Median calculated blood loss was increased in patients taking antiplatelet drugs (1275 mL vs. 1059 mL, P < 0.001) but not in patients taking warfarin or DOACs (913 mL or 859 mL vs. 1059 mL). Antiplatelet drugs were independently associated with an odds ratio of transfusion of 1.45 [95% confidence interval (CI), 1.1-1.9] in contrast with 0.76 (95% CI, 0.5-1.2) for warfarin and 0.67 (95% CI, 0.3-1.4) for DOACs. CONCLUSIONS: Geriatric patients taking warfarin (incompletely reversed) or DOACs lose less blood during cephalomedullary nail fixation of hip fractures than those taking aspirin. Delaying surgery to mitigate anticoagulant-related surgical blood loss may be unwarranted. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Higher Rates of Readmission After Acute Total Hip Arthroplasty Versus Open Reduction Internal Fixation for Elderly Acetabular Fractures, a National Study From 2010 to 2019.

OBJECTIVES: To evaluate the initial complications and short-term readmissions and reoperations after open reduction internal fixation (ORIF) versus acute total hip arthroplasty (THA) for elderly acetabular fractures. DESIGN: Retrospective database review. SETTING: All hospitalizations in the National Readmissions Database and National Inpatient Sample. PATIENTS/PARTICIPANTS: Patients 60 years of age or older with closed acetabular fractures managed surgically identified from the National Readmissions Database or National Inpatient Sample between 2010 and 2019. INTERVENTION: Acute THA with or without ORIF. MAIN OUTCOME MEASUREMENTS: 30-, 90-, and 180-day readmissions and reoperations and index hospitalization complications. RESULTS: An estimated 12,538 surgically managed acetabular fractures in elderly patients occurred nationally between 2010 and 2019, with 10,008 (79.8%) undergoing ORIF and 2529 (20.2%) undergoing THA. Length of stay was 1.7 days shorter ( P < 0.001) and probability of nonhome discharge was reduced (OR 0.68, P = 0.009) for THA patients than for ORIF patients. THA was associated with lower rates of pneumonia (4.6 vs. 9.1%, P < 0.001) and other respiratory complications (10.2 vs. 17.6%) when compared with ORIF. At 30 days, THA patients had higher rates of readmission (13.9 vs. 10.1%, P = 0.007), related readmission (5.4 vs. 1.2%, P < 0.001), readmission for dislocation (3.1 vs. 0.3%, P < 0.001), and reoperations (2.9 vs. 0.9%, P = 0.002). At 180 days, THA patients had higher rates of related readmission (10.1% vs. 3.9%, P < 0.001), readmission for dislocation (5.1% vs. 1.3%, P < 0.001), and readmission for SSI (3.4 vs. 0.8%, P = 0.005). CONCLUSIONS: Acute THA is associated with lower length of stay and certain index hospitalization complications, but higher rates of readmissions for related reasons and specifically for dislocation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis.

BACKGROUND: In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling. DISCUSSION: Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D. LEVEL OF EVIDENCE: III.

Lower Risk of Revision Surgery After Arthroscopic Versus Open Irrigation and Débridement for Shoulder Septic Arthritis.

BACKGROUND: In the treatment of native shoulder septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival (RFS), complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D) were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 4,113 patients with native shoulder septic arthritis undergoing I&D were identified, 2,775 arthroscopic (67.5%) and 1,338 open (32.5%). The median follow-up was 170 days (interquartile range 79 to 265). A total of 341 patients (8.3%) underwent revision I&D at a median of 9 days. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $4,154 ( P < 0.001) and length of stay of 0.78 days ( P = 0.030). Arthroscopic I&D was associated with reduced blood transfusions (odds ratio 0.69, P = 0.001) and wound complications (odds ratio 0.30, P < 0.001). RFS was 96.4%, 94.9%, 93.3%, and 92.6% for arthroscopic I&D and 94.1%, 92.6%, 90.4%, and 89.0% for open I&D at 10, 30, 90 and 180 days, respectively ( P = 0.00043). On multivariate Cox modeling, arthroscopic I&D was associated with improved survival (hazard ratio 0.67, P = 0.00035). On stratified analysis, arthroscopic I&D was associated with improved RFS in patients aged 65 years or older ( P < 0.001), but RFS was similar in those younger than 65 years ( P = 0.17). CONCLUSION: Risk of revision I&D was markedly lower after arthroscopic I&D compared with open, although the protective benefit was limited to patients aged 65 years or older. Arthroscopy was also associated with decreased costs, length of stay, and complications. Although surgeons must consider specific patient factors, our results suggest that arthroscopic I&D is superior to open I&D. LEVEL OF EVIDENCE: III.

Association of Hospital Safety Net Status With Outcomes and Resource Use for Extracorporeal Membrane Oxygenation in the United States.

PURPOSE: Safety net hospitals (SNH) have been associated with inferior surgical outcomes and increased resource use. Utilization and outcomes for extracorporeal membrane oxygenation (ECMO), a rescue modality for patients with respiratory or cardiac failure, may vary by safety net status. We hypothesized SNH to be associated with inferior outcomes and costs of ECMO in a national cohort. MATERIALS AND METHODS: The 2008-2017 National Inpatient Sample was queried for ECMO hospitalizations and safety net hospitals were identified. Multivariable regression was used to perform risk-adjusted comparisons of mortality, complications and resource utilization at safety net and non-safety net hospitals. RESULTS: Of 36,491 ECMO hospitalizations, 28.2% were at SNH. On adjusted comparison SNH was associated with increased odds of mortality (AOR: 1.23), tracheostomy use (AOR: 1.51), intracranial hemorrhage (AOR: 1.39), as well as infectious complications (AOR: 1.21, all P < .05), with NSNH as reference. SNH was also associated with increased hospitalization duration (ß=+4.5 days) and hospitalization costs (ß=+$32,880, all P < .01). CONCLUSIONS: We have found SNH to be associated with inferior survival, increased complications, and higher costs compared to NSNH. These disparate outcomes warrant further studies examining systemic and hospital-level factors that may impact outcomes and resource use of ECMO at SNH.

Protective oral vaccination against infectious salmon anaemia virus in Salmo salar.

Infectious salmon anemia (ISA) is a systemic disease caused by an orthomyxovirus, which has a significant economic impact on the production of Atlantic salmon (Salmo salar). Currently, there are several commercial ISA vaccines available, however, those products are applied through injection, causing stress in the fish and leaving them susceptible to infectious diseases due to the injection process and associated handling. In this study, we evaluated an oral vaccine against ISA containing a recombinant viral hemagglutinin-esterase and a fusion protein as antigens. Our findings indicated that oral vaccination is able to protect Atlantic salmon against challenge with a high-virulence Chilean isolate. The oral vaccination was also correlated with the induction of IgM-specific antibodies. On the other hand, the vaccine was unable to modulate expression of the antiviral related gene Mx, showing the importance of the humoral response to the disease survival. This study provides new insights into fish protection and immune response induced by an oral vaccine against ISA, but also promises future development of preventive solutions or validation of the current existing therapies.

A two-year follow-up of oral antioxidant supplementation in primary open-angle glaucoma: an open-label, randomized, controlled trial.

PURPOSE: To evaluate the effect of oral antioxidant supplementation (OAS) on primary open-angle glaucoma (POAG) over a 2-year follow-up period. PATIENTS AND METHODS: In this open-label, randomized controlled trial, 117 eyes of 117 patients with mild or moderate POAG and intraocular pressure under control with topical antiglaucoma medications were recruited and randomly divided into three groups according to supplementation: (1) OAS with (ICAPS R(®) - Alcon Laboratories, n = 26); (2) OAS without ω-3 fatty acids (OFTAN MACULA(®) - Laboratorios Esteve, n = 28); and (3) a control group without OAS (n = 63). They all underwent visual field (VF) tests (Humphrey 24-2) and scans using a Fourier-domain optical coherence tomography (FD-OCT) device (RTVue-100) at the beginning of the study and 2 years later. Mean deviation (MD), standard pattern deviation (PSD), peripapillary retinal nerve fibre layer (RNFL) and macular ganglion cell complex (GCC) parameters were considered for the analysis. Patients were also classified according to MD deterioration (fast deterioration vs. slow deterioration). RESULTS: Visual field global indices, peripapillary RNFL thickness and macular GCC thickness showed no differences among the groups at the beginning and end of the follow-up. Besides all the comparisons among groups for differences before and after the follow-up of the MD, PSD, RNFL and GCC parameters were also non-significant. The proportions of patients according to MD deterioration were similar among the groups and subgroups (p > 0.05 for all the comparisons). CONCLUSION: Oral antioxidant supplementation with or without ω-3 fatty acids does not appear useful as an adjuvant treatment of mild/moderate POAG in the short term.

Comparative study of central corneal thickness using Fourier-domain optical coherence tomography versus ultrasound pachymetry in primary open-angle glaucoma.

PURPOSE: To compare central corneal thickness (CCT) results measured by Fourier-domain optical coherence tomography (FD-OCT) and ultrasound pachymetry (USP) in glaucomatous eyes. METHODS: In this prospective, observational cross-sectional study, 80 eyes of 80 patients with primary open-angle glaucoma (POAG) and no other ocular abnormality were selected: 28 were treated with 1 drug (subgroup 1), 32 with 2 drugs (subgroup 2), and 20 with 3 drugs (subgroup 3). CCT was measured by FD-OCT (RTVue OCT) and USP (Pachymeter Reichert IOPac). Bland-Altman plots were used to assess the agreement between both instruments. The differences between CCTs measured by USP and FD-OCT were compared among the 3 subgroups. RESULTS: The mean CCT was 537.76 ± 32.24 µm and 520.53 ± 30.44 µm for USP and FD-OCT, respectively. A significant difference was found between the mean values obtained by FD-OCT and USP (17.22 ± 7.96 µm, P < 0.001, paired Student t test). A high correlation was obtained for CCT measured by both methods (Pearson correlation coefficient = 0.969; P < 0.001), and there was good agreement between the 2 pachymetry methods. Similar differences in CCT using USP and FD-OCT were found among the 3 treatment subgroups (P > 0.05 in all pairwise comparisons, analysis of variance). CONCLUSIONS: FD-OCT underestimates CCT compared with CCT measured by USP in POAG. Although highly correlated, the difference between these 2 devices can be clinically significant in the context of refractive surgeries in POAG patients but not in intraocular pressure estimation. This difference also seems to be independent of the number of antiglaucoma treatments used.

Comparison of global indices and test duration between two visual field analyzers: Octopus 300 and Topcon SBP-3000.

PURPOSE: To compare the global indices and test duration as measured by Octopus 300 and Topcon SBP-3000 perimeters. To our knowledge, this is the first study performed in this way. METHODS: Eighty eyes of 40 glaucomatous and ocular hypertensive patients with previous perimetric experience had visual field tests with Octopus 300 (TOP strategy) and TOPCON SBP-3000. All pairs of tests were performed randomly on separate days, but within 1 month of each other. Taking into account reliability factors of both perimetric examinations, 54 eyes of thirty patients were eligible. Only one eye from each patient was considered. Mean sensitivity (MS), mean defect (MD), loss of variance (sLV-Octopus- and LV -Topcon-) and test duration times were considered. RESULTS: A significant difference was found between the global indices and duration times of the Octopus and the Topcon perimeters (p < 0.05; Wilcoxon test). Moderate degrees of correlation were obtained for MS (Spearman's rho = 0.635; p < 0.001) and MD (Spearman's rho = 0.592; p = 0.001) measurements. There was no correlation between sLV and LV (Spearman's rho = 0.181; p = 0.337). Agreements between pairs of global indices were low as measured by concordance correlation coefficient. CONCLUSION: Global indices measured by the Octopus and Topcon perimeters are significantly different, so direct comparison of the measured values is not reliable. Because of the poor association and agreement between values obtained by these two perimeters, indirect comparison is also inadvisable.

Central corneal thickness, intraocular pressure, and degree of myopia in an adult myopic population aged 20 to 40 years in southeast Spain: determination and relationships.

OBJECTIVE: To determine the values of, and study the relationships among, central corneal thickness (CCT), intraocular pressure (IOP), and degree of myopia (DM) in an adult myopic population aged 20 to 40 years in Almeria (southeast Spain). To our knowledge this is first study of this kind in this region. METHODS: An observational, descriptive, cross-sectional study was done in which a sample of 310 myopic patients (620 eyes) aged 20 to 40 years was selected by gender- and age-stratified sampling, which was proportionally fixed to the size of the population strata for which a 20% prevalence of myopia, 5% epsilon, and a 95% confidence interval were hypothesized. We studied IOP, CCT, and DM and their relationships by calculating the mean, standard deviation, 95% confidence interval for the mean, median, Fisher's asymmetry coefficient, range (maximum, minimum), and the Brown-Forsythe's robust test for each variable (IOP, CCT, and DM). RESULTS: In the adult myopic population of Almeria aged 20 to 40 years (mean of 29.8), the mean overall CCT was 550.12 µm. The corneas of men were thicker than those of women (P = 0.014). CCT was stable as no significant differences were seen in the 20- to 40-year-old subjects' CCT values. The mean overall IOP was 13.60 mmHg. Men had a higher IOP than women (P = 0.002). Subjects over 30 years (13.83) had a higher IOP than those under 30 (13.38) (P = 0.04). The mean overall DM was -4.18 diopters. Men had less myopia than women (P < 0.001). Myopia was stable in the 20- to 40-year-old study population (P = 0.089). A linear relationship was found between CCT and IOP (R(2) = 0.152, P ≤ 0.001). CCT influenced the IOP value by 15.2%. However no linear relationship between DM and IOP, or between CCT and DM, was found. CONCLUSIONS: CCT was found to be similar to that reported in other studies in different populations. IOP tends to increase after the age of 30 and is not accounted for by alterations in CCT values.

Sexualidad y métodos anticonceptivos en estudiantes de educación secundaria / Knowledge about sexuality and contraceptive methods in highschool students

Introducción: En cada era, ha existido interés en comportamientos sexuales de los adolescentes. Objetivo: Evaluar las características del conocimiento, actitud y práctica sobre sexualidad y métodos anticonceptivos en estudiantes del cuarto y quinto año de educación secundaria del cercado de Ica. Materiales y Métodos: Estudio descriptivo de corte transversal en 489 estudiantes del 4to y 5to año de educación secundaria, durante el año 2002 en el cercado de Ica. Resultados: 50,5 por ciento (247) de los encuestados fueron de sexo femenino encontrándose una media de 15,61. El 49,5 por ciento (242) del total de la muestra fueron de sexo masculino con una media de 15,81. El 47,6 por ciento de los estudiantes señaló que la persona con quien habla de sexo eran los padres. 34,6 por ciento señaló que la fuente de información primaria sobre sexualidad era la madre y el profesor 28,6 por ciento. El 72,2 por ciento perciben que su conocimiento sobre sexualidad es regular y 90,0 por ciento que conoce los métodos anticonceptivos. El 93,5 por ciento está predispuesto a usarlos en una relación sexual, siendo el condón el método que más se usaría (62,4 por ciento). El 61 por ciento de los estudiantes manifestaron tener enamorado(a); 27 por ciento refirieron haber tenido ya relaciones coitales (132). De ellos un 76,5 por ciento usan condón en sus relaciones sexuales, 47 por ciento refiere dificultad en su uso. Conclusiones: Los estudiantes encuestados en el presente trabajo, manifiestan adecuado conocimiento de sexualidad y métodos anticonceptivos, con predisposición a usarlos, sin dejar de lado que este conocimiento debe plasmarse a futuro en una adecuada y mejor práctica de la sexualidad, con mejor conocimiento en métodos anticonceptivos.

Introduction: There has always been interest in studying sexual behaviour of teenagers. Objective: To assess knowledge, attitudes, and practices regarding sexuality and contraceptive methods in 4th and 5th grade highschool students in downtown Ica. Materials and Methods: A descriptive cross-sectional study was performed by interviewing 489 4th and 5th grade highschool students in downtown Ica during 2002. Results: Nearly half the interviewees (50,5 per cent [247]) were female, and their mean age was 15,61 years. Two hundred and forty two (49,5 per cent )were male, and their mean age was 15,81. Nearly forty eight per cent(47,6 per cent) of the students declared that they spoke about sex with their parents. Nearly one third (34,6 per cent) of all students pointed out that their main information source about sexuality was their mothers, and for 28,6 per cent it was school teachers. Seven out of ten students (72,6 per cent) perceived their knowledge abour sex was fair, and 90,0 per cent declared they knew about contraceptive methods; while 93,5 per cent declared they may use them in case of sexual intercourse, being condoms the most widely preferred method (62,4 per cent). Six out of ten students (61per cent) declared they had a boy/girl friend,and 27 per cent (132) declared thay they already had a sexual experience. Out of them, 76,5 per cent declared using condoms regularly for sexual intercourse, and 47 per cent pointed out that condoms were ædifficult for usingÆ. Conclusions: Interviewed high school students have adequate knowledge about sexuality and contraceptive methods, and they are willing to use them, but this must turn into adequate sexuality practices in the future, improving their knowledge on contraceptive methods.

Perspectiva ética de la distribución de recursos: introducción a la justicia sanitaria / Ethical perspective of distribution of resources: introduction to the sanitary justice

Siempre la distribución de recursos económicos tiene un componente ético. Como ética aplicada hay que situarla en su circunstancia. Por lo tanto, varía según su época histórica. En este trabajo se hace un brevísimo recorrido histórico para situarse en el hoy, en que este tema es más candente. Tema siempre abierto a la deliberación y a la racionalidad prudente y responsable.

The distribution of economic resources always has an ethical element. As applied ethics, the same must be placed according to its circumstances, which varies according to its moment in history. We present a brief historical look in order to position ourselves in the present, where the issue has taken on unsuspected importance. Ethics is always open to deliberation, as well as prudent and responsible rationality.

El viejo en la historia / The old person in history

Se hace una breve revisión histórica del papel del hombre viejo durante diferentes períodos de la historia en el mundo occidental. El momento de gloria de los viejos se vivió en las épocas más primitivas, cuando existía una cultura ágrafa. Luego de esos remotos tiempos, su consideración social sufrió diversas vicisitudes. Durante la mayor parte tuvo más bien un rol desmedrado, aunquehay que distinguir entre el viejo como persona individual ûcuyo aprecio está en relación a su poder económico o su prestigioû, al del viejo como estamento social. Transitar por las diversas épocas nos ayuda a comprender la situación de los ancianos en el presente. Condición necesaria para dar respuesta, hoy día, al gran desafío que constituye este grupo etario de rápido crecimiento demográfico.

Los derechos humanos y su vinculación con los derechos de los pacientes / Human rights and their relationship with patientïs rights

This historical article reviews the most important milestones in the evolution of human and patient's rights. The latter have derived from human rights and have followed a similar historical evolution, but in markedly different times. This has lead to the persistence of monarchic type, paternalistic clinical relationship forms in republican societies. The acceptance of informed consent and patient's rights has been a democratization of clinical relationships. On the other hand the right to body health management is a real cultural revolution. The democratization of clinical relationship is in agreement with our technical, pluralist and secularized times