Hipotiroidismo consuntivo en paciente con hipotiroidismo primario previo / Consumptive hypothyroidism in patient with previous primary hypothyroidism

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Somatic activating mutations in PIK3CA cause generalized lymphatic anomaly.

Generalized lymphatic anomaly (GLA) is a vascular disorder characterized by diffuse or multifocal lymphatic malformations (LMs). The etiology of GLA is poorly understood. We identified four distinct somatic PIK3CA variants (Glu542Lys, Gln546Lys, His1047Arg, and His1047Leu) in tissue samples from five out of nine patients with GLA. These same PIK3CA variants occur in PIK3CA-related overgrowth spectrum and cause hyperactivation of the PI3K-AKT-mTOR pathway. We found that the mTOR inhibitor, rapamycin, prevented lymphatic hyperplasia and dysfunction in mice that expressed an active form of PIK3CA (His1047Arg) in their lymphatics. We also found that rapamycin reduced pain in patients with GLA. In conclusion, we report that somatic activating PIK3CA mutations can cause GLA, and we provide preclinical and clinical evidence to support the use of rapamycin for the treatment of this disabling and deadly disease.

Clinical and metabolic profile of patients with latent autoimmune diabetes in adults in specialized care in Madrid. / Perfil clínico y metabólico de pacientes con diabetes tipo LADA atendidos en atención especializada en la comunidad de Madrid.

OBJECTIVE: To report the clinical characteristics of patients with latent autoimmune diabetes in adults (LADA), and to ascertain their metabolic control and associated chronic complications. METHODS: Patients with DM attending specialized medical care in Madrid who met the following criteria: age at diagnosis of DM >30years, initial insulin independence for at least 6months and positive GAD antibodies were enrolled. Clinical profiles, data on LADA diagnosis, associated autoimmunity, C-peptide levels, therapeutic regimen, metabolic control, and presence of chronic complications were analyzed. RESULTS: Number of patients; 193; 56% females. Family history of DM: 62%. Age at DM diagnosis: 49years. Delay in confirmation of LADA: 3.5years. Insulin-independence time: 12months. Baseline serum C-peptide levels: 0.66ng/ml. Basal-bolus regimen: 76.7%. Total daily dose: 35.1U/day, corresponding to 0.51U/Kg. With no associated oral antidiabetic drugs: 33.5%. Other autoimmune diseases: 57%. Fasting plasma glucose: 160.5mg/dL. HbA1c: 7.7%. BMI: 25.4kg/m2 (overweight, 31.5%; obesity, 8%). Blood pressure: 128/75. HDL cholesterol: 65mg/dL. LDL cholesterol: 96mg/dL. Triglycerides: 89mg/dL. Known chronic complications: 28%. CONCLUSIONS: Recognition of LADA may be delayed by several years. There is a heterogeneous pancreatic insulin reserve which is negative related to glycemic parameters. Most patients are poorly controlled despite intensive insulin therapy. They often have overweight, but have adequate control of BP and lipid profile and a low incidence of macrovascular complications.

Perfil clínico y metabólico de pacientes con diabetes tipo LADA atendidos en atención especializada en la comunidad de Madrid / Clinical and metabolic profile of patients with latent autoimmune diabetes in adults in specialized care in Madrid

Objetivo: Definir las características clínicas de los pacientes con diabetes autoinmune latente del adulto (LADA), conocer su control metabólico y las complicaciones crónicas asociadas que presentan. Métodos: Seleccionamos pacientes con DM seguidos en las consultas de endocrinología de hospitales públicos de la Comunidad de Madrid que reunían los siguientes criterios: edad al diagnóstico de DM >30años, independencia inicial de insulina durante al menos 6meses y positividad de anticuerpos antiGAD. Analizamos datos clínicos relativos al diagnóstico de LADA, autoinmunidad asociada, niveles de péptidoC, pauta terapéutica, control metabólico y presencia de complicaciones crónicas. Resultados: Número de pacientes: 193. Mujeres: 56%. Antecedentes familiares de DM: 62%. Edad al diagnóstico de DM: 49años. Retraso en confirmación LADA: 3,5años. Tiempo de insulino-independencia: 12meses. PéptidoC basal suero: 0,66ng/ml (0,22nmol/l). Pauta de insulina basal-bolus: 76,7%. Dosis total diaria: 35,1U/día, correspondiente a 0,51U/kg. Sin fármacos orales asociados: 33,5%. Presencia de otras patologías autoinmunes: 57%. Glucemia en ayunas: 160,5mg/dl (8,91mmol/l). HbA1c: 7,7%. IMC: 25,4kg/m2 (sobrepeso: 31,5%; obesidad: 8%). Presión arterial: 128/75. Colesterol HDL: 65mg/dl (16,9mmol/l). Colesterol LDL: 96mg/dl (24,96mmol/l). Triglicéridos: 89mg/dl (1,01mmol/l). Complicaciones crónicas: 28%; microangiopatía: 23,1%; macroangiopatía: 4,9%. Conclusiones: El reconocimiento de LADA puede retrasarse varios años. La reserva pancreática de insulina de los pacientes es heterogénea y el grado medio de control glucémico deficiente a pesar de utilizar mayoritariamente insulinoterapia intensiva. Con frecuencia presentan sobrepeso, aunque tienen un control adecuado de la presión arterial y perfil lipídico y baja incidencia de complicaciones macroangiopáticas (AU)

Objective: To report the clinical characteristics of patients with latent autoimmune diabetes in adults (LADA), and to ascertain their metabolic control and associated chronic complications. Methods: Patients with DM attending specialized medical care in Madrid who met the following criteria: age at diagnosis of DM >30years, initial insulin independence for at least 6months and positive GAD antibodies were enrolled. Clinical profiles, data on LADA diagnosis, associated autoimmunity, C-peptide levels, therapeutic regimen, metabolic control, and presence of chronic complications were analyzed. Results: Number of patients; 193; 56% females. Family history of DM: 62%. Age at DM diagnosis: 49years. Delay in confirmation of LADA: 3.5years. Insulin-independence time: 12months. Baseline serum C-peptide levels: 0.66ng/ml. Basal-bolus regimen: 76.7%. Total daily dose: 35.1U/day, corresponding to 0.51U/Kg. With no associated oral antidiabetic drugs: 33.5%. Other autoimmune diseases: 57%. Fasting plasma glucose: 160.5mg/dL. HbA1c: 7.7%. BMI: 25.4kg/m2 (overweight, 31.5%; obesity, 8%). Blood pressure: 128/75. HDL cholesterol: 65mg/dL. LDL cholesterol: 96mg/dL. Triglycerides: 89mg/dL. Known chronic complications: 28%. Conclusions: Recognition of LADA may be delayed by several years. There is a heterogeneous pancreatic insulin reserve which is negative related to glycemic parameters. Most patients are poorly controlled despite intensive insulin therapy. They often have overweight, but have adequate control of BP and lipid profile and a low incidence of macrovascular complications (AU)

Georreferenciación de la oferta de programas de salud pública en cuatro ciudades en el contexto del mercado competitivo del sistema de salud, Colombia 2014 / Georreferenciamento da oferta de programas de saúde pública em quatro cidades no contexto do mercado competitivo do sistema de saúde, Colômbia / Georeferencing provision of public health programs in four Colombian cities within the context of the competitive market of the health system, 2014

Objetivo: georreferenciar la oferta de programas de salud pública de las Instituciones Prestadoras de Servicios de Salud (IPS) públicas y privadas en cuatro ciudades colombianas. Metodología: estudio descriptivo de corte transversal, desarrollado a partir de la base de datos de IPS habilitadas del Ministerio de Salud y Protección Social, que ofrecen programas de salud pública. Resultados: es mayor el número de IPS privadas que ofrecen programas de salud pública; sin embargo, estas se concentran en atender a la población y las zonas de la ciudad con mejor nivel socioeconómico. La población de las zonas más pobres está siendo atendida casi exclusivamente por las IPS del sector público. Conclusión: en un sistema de mercado competitivo la población y las zonas de la ciudad se segmentan según su nivel socioeconómico y no es atractivo para el sector privado proveer servicios de salud pública a las poblaciones más pobres.

Objective: To describe the geographical location of public health programs offered by public and private institutions providing health services in four Colombian cities. Methodology: Descriptive cross-sectional study based on information from the Ministry of Health of institutions that provide public health programs. Results: More private than public institutions offer public health programs, but the former are concentrated on the population and zones with better socioeconomic conditions. In contrast, poor population depends almost exclusively on public sector institutions. Conclusion: In a competitive market system, population and city zones are segmented according to their socioeconomic level, and it is not attractive for the private sector to provide public health services to poorer populations.

Objetivo: georreferenciar a oferta de programas de saúde pública das instituições prestadoras de serviços de saúde (IPS) públicas e privadas em quatro cidades colombianas. Metodologia: estudo descritivo de corte transversal, desenvolvido a partir da base de dados de IPS habilitadas do Ministério de Saúde e Proteção Social, que oferecem programas de saúde pública. Resultados: é maior o número de IPS privadas que oferecem programas de saúde pública; no entanto, estas se concentram em atender à população e as zonas da cidade com melhor nível socioeconômico. A população das zonas mais pobres está sendo atendida quase exclusivamente pelas IPS do setor público. Conclusão: num sistema de mercado competitivo a população e as zonas da cidade se segmentam segundo seu nível socioeconômico e não é atraente para o setor privado prover serviços de saúde pública às populações mais pobres.

[Conflicting values in Colombia's health system: balancing the market economy and constitutional legislation, 2007-2009]. / Conflicto de valores en el sistema de salud de Colombia: entre la economía de mercado y la normativa constitucional, 2007-2009.

OBJECTIVE: To present the conflicting moral issues that arise in clinical and administrative decision-making processes in Colombia's General Health Social Security System (SGSSS). METHODS: A study was conducted between 2007 and 2009 in six Colombian cities (Barranquilla, Bogotá, Bucaramanga, Leticia, Medellín, and Pasto) using a theory-based qualitative methodology. A total of 179 in-depth interviews were held with physicians, nursing personnel, and administrators with broad experience in the health sector, as well as 10 focus groups representing users and leaders of community organizations involved in health. The interviews, which followed a predetermined script and used semistructured questions, gathered personal and professional information from the respondents. RESULTS: The health care decision-making process in Colombia is seen from two different moral perspectives: the rentier, or profit-making, motive, characterized by a neoliberal view of the market economy (the practical perspective), and the constitutional axiology of social democracy (the regulatory perspective). It was found that the utilitarian and individualistic motive predominates, in which individual and business profits are promoted over the collective interest, and this trend favors practices that undermine the rights of people and the community. CONCLUSIONS: Predominance of a morality that views the Colombian SGSSS in terms of the market model generates conditions that go against the principles and values that are supposed to guide the health system as guarantor of the right to health and human dignity. Health decisions should take into account not only technical and scientific criteria but also the principles and values involved, and consideration should be given to safeguarding them.

Conflicto de valores en el sistema de salud de Colombia: entre la economía de mercado y la normativa constitucional, 2007-2009 / Conflicting values in Colombia's health system: balancing the market economy and constitutional legislation, 2007-2009

OBJETIVO: Presentar los aspectos morales en conflicto en los procesos de toma de decisiones clínico-administrativas dentro del Sistema General de Seguridad Social en Salud (SGSSS) de Colombia. MÉTODOS: La investigación se llevó a cabo entre 2007 y 2009 en seis ciudades colombianas (Barranquilla, Bogotá, Bucaramanga, Leticia, Medellín y Pasto), según una metodología cualitativa basada en la teoría fundamentada. Se realizaron 179 entrevistas en profundidad a médicos, personal de enfermería y administradores con amplia experiencia en el sector de la salud, y 10 grupos focales con usuarios y líderes de organizaciones comunitarias vinculadas a la salud. Las entrevistas, con preguntas semiestructuradas y según una guía elaborada previamente, recababan información personal y profesional. RESULTADOS: En el proceso de toma de decisiones en la atención en salud en Colombia se identificaron elementos de dos morales enfrentadas: la rentista, caracterizada por la axiología neoliberal de la economía de mercado (práctica) y otra fundamentada en la axiología constitucional (normativa) del Estado social de derecho. Predomina el enfoque utilitarista e individualista y se promueve el lucro individual y empresarial por encima del interés colectivo; esto favorece prácticas que contravienen los derechos de las personas y la comunidad. CONCLUSIONES: El predominio de la moral que responde al modelo de mercado en el SGSSS colombiano genera condiciones adversas a los principios y valores que deben orientar el sistema de salud como garante del derecho a la salud y la dignidad humana. Para la toma de decisiones en salud es necesario tener en cuenta, además de los elementos técnicos y científicos, los principios y valores que están enfrentados y reflexionar sobre ellos para su legitimación.

OBJECTIVE: To present the conflicting moral issues that arise in clinical and administrative decision-making processes in Colombia's General Health Social Security System (SGSSS). METHODS: A study was conducted between 2007 and 2009 in six Colombian cities (Barranquilla, Bogotá, Bucaramanga, Leticia, Medellín, and Pasto) using a theory-based qualitative methodology. A total of 179 in-depth interviews were held with physicians, nursing personnel, and administrators with broad experience in the health sector, as well as 10 focus groups representing users and leaders of community organizations involved in health. The interviews, which followed a predetermined script and used semistructured questions, gathered personal and professional information from the respondents. RESULTS: The health care decision-making process in Colombia is seen from two different moral perspectives: the rentier, or profit-making, motive, characterized by a neoliberal view of the market economy (the practical perspective), and the constitutional axiology of social democracy (the regulatory perspective). It was found that the utilitarian and individualistic motive predominates, in which individual and business profits are promoted over the collective interest, and this trend favors practices that undermine the rights of people and the community. CONCLUSIONS: Predominance of a morality that views the Colombian SGSSS in terms of the market model generates conditions that go against the principles and values that are supposed to guide the health system as guarantor of the right to health and human dignity. Health decisions should take into account not only technical and scientific criteria but also the principles and values involved, and consideration should be given to safeguarding them.

[Cost-effectiveness of an alternative tuberculosis treatment: home-based guardian monitoring of patients]. / Costo-efectividad de un tratamiento antituberculoso alternativo: seguimiento a convivientes residenciales de los pacientes.

OBJECTIVE: Estimate the cost-effectiveness ratio of the directly observed treatment short course (DOTS) for treatment of tuberculosis (TB), comparing it to a variation of this treatment that includes increased home-based guardian monitoring of patients (DOTS-R). METHODS: Taking a social perspective that includes the costs for the health institutions, the patients, and their family members, and for other entities that contribute to making operation of the program effective, the costs incurred with each of the two strategies were evaluated and the cost-effectiveness ratios were estimated adopting the measures of effect used by the control programs. The estimate of the cost of each of the two strategies includes the cost to the health institutions that administer treatment, the patients and their family members, and the cost to the Ministry of Health that manages public health programs on the municipal level. Based on these costs and the number of cases cured and treatments completed as outcome measures of each of the strategies evaluated, the cost-effectiveness ratio and incremental cost were calculated. RESULTS: The DOTS-R was found to be more cost-effective for achievement of successful treatments than the DOTS. The DOTS-R recorded costs of US$ 1 122.40 to US$ 1 152.70 for each case cured compared to values of US$ 1 137.00 to US$ 1 494.30 for the DOTS. The percentage of cases treated successfully was higher with DOTS-R than with DOTS. CONCLUSIONS: The DOTS-R is a promising cost-effective alternative for improved control of TB in endemic areas. It is recommended that the health authorities include home-based guardian monitoring of patients in their institutional management of the TB program, with the participation of health workers and the physical and financial resources that currently support this program.

Costo-efectividad de un tratamiento antituberculoso alternativo: seguimiento a convivientes residenciales de los pacientes / Cost-effectiveness of an alternative tuberculosis treatment: home-based guardian monitoring of patients

Objetivo. Estimar la relación de costo-efectividad del tratamiento de corta duración bajoobservación directa (DOTS), comparándolo con una variación de dicho tratamiento, que incluyeun mayor seguimiento a los convivientes residenciales de los pacientes (DOTS-R) parael tratamiento de tuberculosis (TB).Métodos. Tomando una perspectiva social que incluye los costos para las institucionesde salud, para los pacientes y sus familiares, y para otras entidades que contribuyen a hacerefectiva la operación del programa, se evaluaron los costos incurridos con cada una de las dosestrategias y se estimaron razones costo-efectividad adoptando las medidas de efecto usadas porlos programas de control. La estimación de los costos de cada una de las dos estrategias incluyelos correspondientes a las instituciones de salud que administran el tratamiento, los pacientesy sus familiares, y los de la secretaría de salud que gestiona los programas de salud pública anivel municipal. Con base en estos costos y el número de casos curados y tratamientos terminadoscomo medidas de resultado de cada una de las estrategias evaluadas, se calcularon lasrazones costo-efectividad y costo incremental.Resultados. El DOTS-R se halló más costo-efectivo para lograr tratamientos exitosos queel DOTS. El DOTS-R registró costos de entre US$ 1 122,4 y US$ 1 152,7 por caso curado,comparados con valores de entre US$ 1 137,0 y US$ 1 494,3 correspondientes al DOTS. Laproporción de casos tratados con éxito fue mayor con DOTS-R que con DOTS.Conclusiones. El DOTS-R es una alternativa costo-efectiva promisoria para mejorar elcontrol de la TB en sitios endémicos. Se recomienda a las autoridades del sector salud incorporaren su gestión institucional del programa contra la TB, acciones de seguimiento de losconvivientes de pacientes, con la participación del personal de salud y los recursos físicos yfinancieros que apoyan actualmente dicho programa.

Objective. Estimate the cost-effectiveness ratio of the directly observed treatmentshort course (DOTS) for treatment of tuberculosis (TB), comparing it to a variation ofthis treatment that includes increased home-based guardian monitoring of patients(DOTS-R).Methods. Taking a social perspective that includes the costs for the healthinstitutions, the patients, and their family members, and for other entities thatcontribute to making operation of the program effective, the costs incurred with eachof the two strategies were evaluated and the cost-effectiveness ratios were estimatedadopting the measures of effect used by the control programs. The estimate of the costof each of the two strategies includes the cost to the health institutions that administertreatment, the patients and their family members, and the cost to the Ministry ofHealth that manages public health programs on the municipal level. Based on thesecosts and the number of cases cured and treatments completed as outcome measuresof each of the strategies evaluated, the cost-effectiveness ratio and incremental costwere calculated.Results. The DOTS-R was found to be more cost-effective for achievement ofsuccessful treatments than the DOTS. The DOTS-R recorded costs of US$ 1 122.40 toUS$ 1 152.70 for each case cured compared to values of US$ 1 137.00 to US$ 1 494.30for the DOTS. The percentage of cases treated successfully was higher with DOTS-Rthan with DOTS.Conclusions. The DOTS-R is a promising cost-effective alternative for improvedcontrol of TB in endemic areas. It is recommended that the health authorities includehome-based guardian monitoring of patients in their institutional management of theTB program, with the participation of health workers and the physical and financialresources that currently support this program.

Detección de hepatitis B oculta en donantes de bancos sangre, Colombia 2008-2009 / Absence of occult hepatitis B in Colombian blood donors

Introducción. En los bancos de sangre colombianos es obligatoria la tamización para el antígeno de superficie de la hepatitis B en todas las unidades recolectadas, mientras que no lo es para el anticuerpo contra el antígeno central, aunque este último puede ser útil para detectar donantes infectados con el virus de hepatitis B. Objetivo. Determinar la prevalencia de hepatitis B oculta, mediante la aplicación de un perfil serológico completo para el virus de la hepatitis B y pruebas de amplificación de ácidos nucleicos, en donantes de sangre de cuatro ciudades colombianas. Materiales y métodos. Entre abril de 2008 y octubre de 2009 se llevó a cabo un estudio prospectivo transversal que incluyó 628 muestras de donantes de cuatro bancos de sangre, ubicados en ciudades colombianas que registran distintas prevalencias para infección por el virus de la hepatitis B. Se hizo la tamización serológica completa para el virus y, posteriormente, pruebas de amplificación de ácidos nucleicos a los sueros con anti-HBc total reactivo y título de anti-HBs ≤30 mUI/ml. Resultados. En total, 129 muestras cumplieron con los criterios serológicos establecidos para ser sometidas a pruebas de amplificación de ácidos nucleicos. En ninguna de ellas se obtuvo amplificación de ácidos nucleicos del virus de la hepatitis B. Conclusiones. Éste es el primer estudio en Colombia que busca determinar la presencia de donantes de sangre portadores de hepatitis B oculta. No se documentó ningún caso de infección oculta en elestudio.

Introduction. In Colombian blood banks, screening for the surface antigen of hepatitis B is mandatory in all units collected. Testing of antibody against core antigens is not administered, although this method may be useful to detect donors infected with the hepatitis B virus. Objective. The prevalence of occult hepatitis B was determined by applying a full-serological profile of hepatitis B virus to blood samples of blood donors. Materials and methods. Between April 2008 and October 2009, a prospective cross sectional study was conducted using 628 samples from donors to blood banks located in four Colombian cities. Prevalence for hepatitis B had been previously recorded for these cities. Serological screening was performed for the complete virus; then nucleic acid amplification was tested in sera that were anti-HB creactive and with a titer of anti-HBs ≤30 mUI/ml. Results. Of the 628 samples tested, 129 met the serological criteria established to be tested nucleic acid amplification. None of them demonstrated evidence of nucleic acid amplification of hepatitis B virus. Conclusions. This is the first study in Colombia to detect the presence of blood donors that may be occult hepatitis B carriers. None was detected.

La calidad de servicios maternos en un ambiente de mercado: Medellín, Colombia 2008-2009 / Compromised quality of maternal healthcare in a market economy: Medellín, Colombia 2008-2009

Objetivo: Analizar la calidad de los servicios maternos en la ciudad de Medellín, Colombia, en el Sistema General deSeguridad Social en Salud, desde la perspectiva de la madres usuarias de los servicios maternos y del personal involucradodirectamente en la prestación de estos.Metodología: Se llevó a cabo un estudio con enfoque cualitativo; se realizaron 24 entrevistas individuales a médicos yenfermeras que prestan servicios maternos y se llevaron a cabo tres grupos focales con maternas embarazadas o en períodode posparto. El análisis de la información se realizó mediante un proceso sistemático de codificación y categorización.Hallazgos: A pesar de las políticas internacionales, nacionales y municipales puestas en marcha para mejorar la atenciónmaterna y perinatal, las madres enfrentan constantes problemas de acceso y calidad en los servicios. Son aspectos que afectannegativamente la calidad de la atención los mecanismos de contención de los costos de personal que aplican las diferentesinstituciones, las barreras administrativas, las bajas tarifas por los servicios obstétricos que pagan las aseguradoras en unmercado competitivo y la búsqueda de rentabilidad financiera.

[Absence of occult hepatitis B in Colombian blood donors]. / Detección de hepatitis B oculta en donantes de bancos sangre, Colombia 2008-2009.

INTRODUCTION: In Colombian blood banks, screening for the surface antigen of hepatitis B is mandatory in all units collected. Testing of antibody against core antigens is not administered, although this method may be useful to detect donors infected with the hepatitis B virus. OBJECTIVE: The prevalence of occult hepatitis B was determined by applying a full-serological profile of hepatitis B virus to blood samples of blood donors. MATERIALS AND METHODS: Between April 2008 and October 2009, a prospective cross sectional study was conducted using 628 samples from donors to blood banks located in four Colombian cities. Prevalence for hepatitis B had been previously recorded for these cities. Serological screening was performed for the complete virus; then nucleic acid amplification was tested in sera that were anti-HBc reactive and with a titer of anti-HBs ≤30 mUI/ml. RESULTS: Of the 628 samples tested, 129 met the serological criteria established to be tested nucleic acid amplification. None of them demonstrated evidence of nucleic acid amplification of hepatitis B virus. CONCLUSIONS: This is the first study in Colombia to detect the presence of blood donors that may be occult hepatitis B carriers. None was detected.

Acceso a los servicios de salud en seis ciudades de Colombia: limitaciones y consecuencias / Access to health services in six Colombian cities: limitations and consequences

Objetivo comprender las características del acceso al Sistema General de Seguridad Social en Salud (SGSSS), desde la perspectiva de los médicos, enfermeras, administradores y usuarios. Metodología: bajo la teoría fundada se presenta un estudio realizado en seis ciudades de Colombia: Barranquilla, Bucaramanga, Bogotá, Leticia, Medellín y Pasto, para la cual se realizaron entrevistas en profundidad a profesionales de la salud vinculados en la prestación de servicios y grupos focales con usuarios de los servicios. Resultados: los hallazgos señalan que el aseguramiento se convirtió en un fin en sí mismo y estar afiliado al SGSSS no garantiza el acceso efectivo a los servicios. El predominio del mercado, la rentabilidad financiera de las aseguradoras, impone mecanismos de contención de costos por encima del derecho de la salud. Hay limitaciones desde las normas, los planes de beneficios que generan barreras administrativas, geográficas, económicas y culturales desde los diferentes actores involucrados en la cadena de las decisiones. Adicionalmente, se visualizan carencias éticas individuales e institucionales, el clientelismo y la corrupción en el manejo de los recursos, que sumados a la pobreza y dispersión geográfica de algunas comunidades, hacen que se limite aún más el acceso a los servicios de salud.

Objective: To understand the characteristics of access to the General System of Social Security in health (SGSS), from the perspective of doctors, nurses, administrators and users. Results: The findings indicate that insurance has become an end in itself, and being affiliated that insurance has become an end in itself, and being affiliated to SGSSS does not guarantee effective access to services. The dominance of the market, the financial profitability of insures, imposed cost-containment mechanisms over the right to health. There are limitations from the rules, benefit plans that create geographical, economic and cultural barriers from the various actors involved in the chain of decisions. Additionally, display individual and institutional ethical shortcomings, clienteles and corruption in the management of resources, coupled with poverty and geographical dispersion of communities, mean that further limiting access to health services.

La legislación que regulamenta el sistema de salud colombiano: formulación, aplicación e implicaciones sobre sus actores / Lesgilation regulating the Colombian health system: formulation, implementation and implications on its agents

El sistema de salud colombiano, la legislación cumple el papel de determinar su estructura y funcionamiento en aras de la garantía de los derechos a la salud y la seguridad social incluidos en la Constitución de 1991. Objetivo: presentar las problemáticas en la formulación e implementación de la legislación del actual sistema, así como las implicaciones sobre sus diferentes actores. Metodología: estudio realizado en seis ciudades colombianas usando la metodología cualitativa de la teoría fundada. Se realizaron 174 entrevistas a médicos, administradores, enfermeras y usuarios. Resultados: los hallazgos evidencian problemas en la formulación e implementación, entre ellos: la sobreproducción y las dificultades para la aprehensión, la influencia de intereses particulares y la no correspondencia de las normas con las necesidades de salud la población. Discusión: estas problemáticas causan barreras de acceso a los servicios de salud y fallos en la calidad de la atención a los pacientes, dilemas éticos e insatisfacción e los profesionales de la salud, así como inestabilidad para las instituciones en los profesionales de la salud. Lo anterior emerge como limitación para la garantía del derecho a la salud y exige un replanteamiento de la legislación a favor de los principios constitucionales y el bienestar colectivo.

In the Colombian health system, the legislation complies with the role of determining its structure and function in order to guarantee the rights to health and social security included in the 1991 Constitution. Objective: to present the issues in the formulation and implementation of legislation in the implications of their various agents. Methodology: a study in six Colombian cities using qualitative methodology based on the theory. 174 interviews were conducted with doctors, administrators nurses and users. Results: the findings reveal problems in the formulation and implementation, including: over-regulation and the difficulties of his apprehension, the influence of special interests and not matching the standards with the needs of the accessing health. Discussion: these problems cause barriers to accessing health services and failures in the quality of patient care, ethical dilemmas and dissatisfaction with health professionals, as well as instability in the health sector institutions. This emerges as a constraint of the law in favor of the constitutional principles and the collective welfare.

Rol de los partidos políticos en la provisión de servicios de salud, Colombia 2007-2008 / Role of the political parties in the provision of health services, Colombia 2007-2008

Este manuscrito presenta una de las trece categorías que emergieron de un estudio cuyo objetivo fue comprender las decisiones en la atención en salud en los ambientes controlados en el contexto del Sistema General de Seguridad Social en Salud (SGSS) de Colombia. Esta categoría se centra en describir el papel que juegan los partidos políticos en los procesos de provisión de servicios de salud. Metodología: la investigación se llevó a cabo en seis ciudades capitales de departamento, donde se realizaron, en promedio, 29 entrevistas en profundidad por ciudad, a médicos, enfermeras y administradores (179 en total), pertenecientes a 96 instituciones de salud públicas y privadas. También se realizaron 10 grupos focales con usuarios de los servicios de salud. Resultados: El nexo entre Estado-partidos políticos y provisión de servicios públicos se refleja en el sistema de salud colombiano. Con la descentralización y el SGSS, las relaciones e intereses de los partidos políticos con las élites económicas y el clientelismo como expresión de la negación de la función pública, se han fortalecido y dominan las decisiones económicas, políticas y administrativas, claves del sistema de salud. El SGSS, como política de salud fundamental en el enfoque neoliberal, y las prácticas clientelistas de salud, sino los privados, lo que entra en conflicto con los principios y derechos establecidos en la Constitución Política de Colombia de 1991.

Objective: This paper presents one of the categories that emerged from a study carried out to achieve a comprehension of decisions related to delivering health services, within a restrictive environment offered by the Colombian Social Security System for Health. Methodology: the study was carried out in six cities of department, which conducted an average of 29 in-depth interviews by city, doctors, nurses and administrators (179 in total), blogging to 96 public and private health institutions. Also 10 focus groups with users of health services were carried out. Results: the nexus between the state institutions and the political parties is preset into the whole processes of provision of health services in the Colombian health system. With the decentralization process and the social Security System for Health, the nexus between the political parties, the economic groups involved as health insures and the political patronage have been strengthened, and dominate and control the political, economical and administrative decisions of the health system. The Social Security System for Health, as health policy, founded on neo-liberal approach, and the public values rather than they promote private interests, which generates conflicts with the values and the citizen rights established in the Colombian Political Constitution of 1991.

Determinants of late disease-stage presentation at diagnosis of HIV infection in Venezuela: a case-case comparison.

BACKGROUND: Although Venezuela has a National Human Immunodeficiency Virus (HIV) Program offering free diagnosis and treatment, 41% of patients present for diagnosis at a later disease-stage, indicating that access to care may still be limited. Our study aimed to identify factors influencing delay in presenting for HIV-diagnosis using a case-case comparison. A cross-sectional survey was performed at the Regional HIV Reference Centre (CAI), Carabobo Region, Venezuela. Between May 2005 and October 2006 225 patients diagnosed with HIV at CAI were included and demographic, behavioural and medical characteristics collected from medical files. Socio-economic and behavioural factors were obtained from 129 eligible subjects through interviews. "Late presentation" at diagnosis was defined as patients classified with disease-stage B or C according to the 1993 Centers for Disease Control and Prevention (Atlanta, USA) classification, and "early presentation" defined as diagnosis in disease-stage A. RESULTS: Of 225 subjects, 91 (40%) were defined as late presenters. A similar proportion (51/129) was obtained in the interviewed sub-sample. Older age (>30 years), male heterosexuality, lower socio-economic status, perceiving ones partner to be faithful and living >/= 25 km from the CAI were positively associated with late diagnosis in a multivariate model. Females were less likely to present late than heterosexual males (odds ratio = 0.23, P = 0.06). The main barriers to HIV testing were low knowledge of HIV/AIDS, lack of awareness of the free HIV program, lack of perceived risk of HIV-infection, fear for HIV-related stigma, fear for lack of confidentiality at testing site and logistic barriers. CONCLUSION: Despite the free Venezuelan HIV Program, poverty and barriers related to lack of knowledge and awareness of both HIV and the Program itself were important determinants in late presentation at HIV diagnosis. This study also indicates that women; heterosexual, bisexual and homosexual men might have different pathways to testing and different factors related to late presentation in each subgroup. Efforts must be directed to i) increase awareness of HIV/AIDS and the Program and ii) the identification of specific factors associated with delay in HIV diagnosis per subgroup, to help develop targeted public health interventions improving early diagnosis and prognosis of people living with HIV/AIDS in Venezuela and elsewhere.