Carbapenem resistance in Enterobacterales bloodstream infections among children with cancer or post-haematopoietic stem cell transplant: a retrospective cohort study.

BACKGROUND: Risk factors for carbapenem resistance in Enterobacterales bloodstream infections among children with cancer or post-HSCT have not been thoroughly explored. METHODS: All children with cancer or post-HSCT who developed Enterobacterales bloodstream infections in two cancer referral centres in major Colombian cities between 2012 and 2021 were retrospectively examined. When the infection episode occurred, carbapenem resistance mechanisms were evaluated according to the available methods. Data were divided in a training set (80%) and a test set (20%). Three internally validated carbapenem-resistant Enterobacterales (CRE) prediction models were created: a multivariate logistic regression model, and two data mining techniques. Model performances were evaluated by calculating the average of the AUC, sensitivity, specificity and predictive values. RESULTS: A total of 285 Enterobacterales bloodstream infection episodes (229 carbapenem susceptible and 56 carbapenem resistant) occurred [median (IQR) age, 9 (3.5-14) years; 57% male]. The risk of CRE was 2.1 times higher when the infection was caused by Klebsiella spp. and 5.8 times higher when a carbapenem had been used for ≥3 days in the previous month. A model including these two predictive variables had a discriminatory performance of 77% in predicting carbapenem resistance. The model had a specificity of 97% and a negative predictive value of 81%, with low sensitivity and positive predictive value. CONCLUSIONS: Even in settings with high CRE prevalence, these two variables can help early identification of patients in whom CRE-active agents are unnecessary and highlight the importance of strengthening antibiotic stewardship strategies directed at preventing carbapenem overuse.

Combining spectral analysis and geochemical tracers to investigate surface water-groundwater interactions: A case study in an intensive agricultural setting (southern Guatemala).

An increase in the frequency of severe hydrological events has highlighted the importance of sustainable water management in intensive agricultural regions. In a warming climate, improved understanding and stewardship of water resources are needed to guarantee water supply, ensure food security, and build resilience against extreme events. In this study, we evaluate a framework that combines spectral analysis and geochemical tracers as a potential tool for (1) gaining valuable insights into surface water (SW)-groundwater (GW) interactions, and (2) providing guidance for improved water management in an intensive agricultural basin in southern Guatemala. The framework proves to be useful in revealing important water dynamics, exposing key feedback mechanisms for water availability and quality. With the use of power density functions and hydrochemistry (T, pH, EC, and major ions), two specific interaction regimes (influent and effluent) were identified and delimited for the main watercourse. These segments are estimated to interact at high rates with the shallow aquifer in the river channel proximities and would lose influence towards the basin flanks. Furthermore, the δ2H and δ18O values indicate that regional groundwater flow systems play an essential role in the basin groundwater recharge. Lastly, we established three influence zones that depict the spatial extent of the SW-GW interactions within the basin. With these zones, we provide recommendations that will allow for further investigation and application into better water management strategies regulating groundwater development and land use activities within the agricultural context of the area.

Correlación de displasia de cadera con factores de riesgo Hospital Municipal Achacachi / Correlation of hip dysplasia with risk factors Hospital Municipal Achacachi

INTRODUCCIÓN: la displasia de cadera es una de las causas más importantes y prevenibles de discapacidad durante la primera infancia. Es una enfermedad que se presenta en niños menores de 1 año, pero puede tener consecuencias importantes en la edad adulta, incluso puede desencadenar una osteoartrosis de cadera y/o invalidez en adultos jóvenes. OBJETIVO: determinar la correlación entre displasia de cadera con sus factores de riesgo en lactantes de 2 a 12 meses, evaluados en consultorio externo de Traumatología del Hospital Municipal Achacachi en el periodo de mayo ­ 2017 hasta abril ­ 2018. MATERIAL Y MÉTODOS: el tipo de investigación es descriptivo, diseño de tipo caso ­ control. Se estudiaron 128 pacientes lactantes de ambos sexos, que asistieron a su control en el consultorio de traumatología. La correlación entre factores de riesgo y displasia de cadera se determinó mediante la fórmula de Odds Ratio. RESULTADOS: el género femenino es el factor de riesgo con mayor asociación con la displasia de cadera, con un Odds Ratio de 139.04 veces más de padecer de displasia de cadera, seguida de la presentación podálica o transversa (12.58), las gestantes primíparas (4.52), los productos gemelares (3.71), los antecedentes familiares (2.54) y el Oligohidramnios (2.06). CONCLUSIÓN: existe relación importante entre los factores de riesgo (clínicos, obstétricos y fetales), con el desarrollo de displasia de cadera.(AU)

INTRODUCTION: hip dysplasia is one of the most important and preventable causes of disability during early childhood. It is a disease that occurs in children younger than 1 year, but it can have important consequences in adulthood, it can even trigger hip osteoarthritis and / or disability in young adults. OBJECTIVE: to determine the correlation between Hip Dysplasia with its risk factors in infants from 2 to 12 months, evaluated in an external Traumatology office of the Hospital Municipal Achacachi in the period from May - 2017 to April - 2018. MATERIAL AND METHODS: the type of research is descriptive, case control type design. 128 lactating patients of both sexes were studied, who attended their control in the traumatology office. The correlation between risk factors and hip dysplasia was determined using the Odds Ratio formula. RESULTS: female gender is the risk factor with the highest association with hip dysplasia, with an Odds Ratio of 139.04 times more than having Hip dysplasia, followed by breech or transverse presentation (12.58), primiparous pregnant women (4.52), twin products (3.71), Family History (2.54) and Oligohydramnios (2.06). CONCLUSIONS: there is an important relationship between risk factors (clinical, obstetric and fetal), with the development of Hip Dysplasia.(AU)

Infectious complications after allogeneic hematopoietic stem cell transplantation in children in a bone marrow transplant unit in Colombia.

OBJECTIVE: There is a relative lack of information about infections occurring in children following allogeneic hematopoietic stem cell transplants (allo-HSCT) in developing countries. Herein, we describe the incidence rates of different infections according to the transplant period and baseline condition in Colombia. METHODS: In a retrospective cohort study of all children who underwent allo-HSCTs from 2012 to 2017 in a hospital in Cali, Colombia, we reviewed medical records from the first post-transplant day until day + 365 to describe microbiologically confirmed incidence rates of infections and deaths during three post-transplant periods and according to baseline condition. RESULTS: Most allo-HSCT (n = 144, 96%) were followed by infections over the following year, mostly due to bacteria and cytomegalovirus (4.3 and 3.3 per 1000 patient-days, respectively). Children were at the highest risk for infection in the first 30 days post-HSTC, but mortality was highest after 100 days. Overall, high mortality (n = 44, 31.7%) was associated with infections, especially from extensively drug-resistant bacteria, adenovirus, and aspergillosis. Infection rates were similar independent of the baseline condition. CONCLUSION: Almost all children in this cohort developed infections post allo-HSCT. Describing the distribution of infections throughout the first post allo-HSCT year allows clinicians to narrow the differential diagnosis of infections according to the post-transplant period. This is especially useful when prioritizing interventions in children receiving HSCT in stringent healthcare systems in developing countries.

Influencia de la autoestima en el rendimiento académico de estudiantes de la carrera de medicina de la Universidad Mayor de San Andrés / Influence of the self esteem on the academic achievement of medicine student at San Andres Univerity

Introducción: Durante el desarrollo del proceso educativo en la Carrera de Medicina, todo docente en algun momento tropezó con inmunerables obstáculos relacionados con el bajo rendimiento académico de sus alumnos, atribuyendose esta situación a la falta de capacidad, irresponsabilidad e interés entre otros factores, sin embargo jamás se tomó en cuenta de elementos subjetivos del educando como lo es la autoestima.

Correlación de valores B-HCG y ultrasonografia intraoperatoria en embarazo ectópico / CORRELATION OF ß-HCG LEVELS AND INTRA-OPERATIVE ULTRASONOGRAPHY IN ECTOPIC PREGNANCY

Introducción: El diagnóstico del embarazo ectópico puede no resultar fácil y se debe realizar con rapidez y seguridad, pues una demora puede conllevar a la ruptura, la hemorragia y poner en peligro la vida de la paciente. Objetivo: Determinar el grado de correlación de valores de β-hCG y ultrasonografía con los hallazgos intra-operatorios de pacientes con diagnóstico de embarazo ectópico en el servicio de Ginecología y Obstetricia del Hospital Municipal Boliviano Holandés. Material y métodos: Estudio descriptivo transversal y retrospectivo. Se estudiaron 115 pacientes con diagnóstico de embarazo ectópico, internadas en el Servicio de Ginecología y Obstetricia del Hospital Municipal Boliviano Holandés, durante el periodo 2010 - 2014. Resultados: La población con mayor frecuencia afectada, es de 20 a 30 años de edad (88,7%). La mayor cantidad de población, se observó durante el año 2014 (47%). La validez de los hallazgos ultrasonográficos es de: Sensibilidad = 98,2% y Especificidad = 75%. La seguridad de los hallazgos ultrasonográficos es de: Valor Predictivo Positivo = 99,1% y Valor Predictivo Negativo = 60%. La validez de los hallazgos ultrasonográficos combinado con la cuantificación sérica de β-hCG es de: Sensibilidad = 99,1% y Especificidad = 100%. La seguridad de los hallazgos ultrasonográficos combinado con la cuantificación sérica de β-hCG es de: Valor Predictivo Positivo = 100% y Valor Predictivo Negativo = 80%. Conclusión: El test diagnóstico ultrasonográfico combinado con la cuantificación sérica de β-hCG tiene mayor validez y seguridad que el test diagnóstico ultrasonográfico solo.

Introduction: The diagnosis for ectopic pregnancy may be difficult, and must be carried out quickly and safely since a delay can lead to rupture, bleeding and endanger the life of the patient. Objective: To determine the correlation degree of β-hCG levels and ultrasonography with the intra-operative findings of patients with ectopic pregnancy diagnosis in the Gynecology and Obstetrics Service at Hospital Municipal Boliviano Holandés. Material and methods: Descriptive, cross-sectional and retrospective study that included 115 patients with ectopic pregnancy diagnosis, and admitted in the Obstetrics and Gynecology Service at Hospital Municipal Boliviano Holandés during the period 2010-2014. Results: The most frequently affected population was 20 to 30 years old (88.7%). Most of the cases were observed during 2014 (47%). Validity of ultrasound findings reflected 98.2% of sensitivity and 75 % of specificity. Safety of ultrasound findings reflected Positive Predictive Value of 99.1 % and Negative Predictive Value of 60 %. Validity of ultrasound findings combined with β-hCG serum quantification displayed a sensitivity of 99.1 % and specificity of100%. Safety of ultrasound findings combined with β-hCG serum quantification displayed a Positive Predictive Value of 100 % and Negative Predictive Value of 80 %. Conclusions: The ultrasonographic diagnostic test combined with the β-hCG serum quantification has better validity and safety than the ultrasonographic test alone.

Prevalence of multiple sclerosis in Cuenca, Ecuador.

BACKGROUND: Cuenca, a city in the Andean Region of southern Ecuador, has 591,996 inhabitants. A decade-old study showed the prevalence of multiple sclerosis in Cuenca was 0.75 cases per 100,000 inhabitants but no new epidemiological studies in this city have been performed since then. The aim of this study, conducted in 2016, was to update the prevalence records of multiple sclerosis in Cuenca. METHODS: We performed a descriptive cross-sectional study in which we investigated prevalence rates in November of 2016. We estimated the prevalence of multiple sclerosis by cross-matching registries from the two neurological referral hospitals in Cuenca. RESULTS: A total of 23 records were obtained from the two sources. The estimated prevalence was 3.88 per 100,000 inhabitants (95% confidence interval: 3.83-3.94). The disease was predominant among women (60%). The mean age of this cohort was 37 years (standard deviation ±12.4). Of the cases, 78% were relapsing-remitting multiple sclerosis. The mean Expanded Disability Status Scale score was 2.5. CONCLUSIONS: This study is an update to the first study conducted 10 years ago and shows the prevalence of multiple sclerosis in Cuenca has increased. However, the prevalence of multiple sclerosis is still low and very similar to that reported in neighbouring countries.

Eficacia del cianoacrilato en el cierre de heridas de pacientes intervenidas mediante cesarea segmentaria, en el Hospital Municipal Boliviano Holandés durante el periódo de Septiembre a Diciembre del 2015 / EFFICACY OF THE CYANOACRYLATE IN THE CLOSING OF INJURIES OF PATIENTS INTERVENED BY MEANS OF SEGMENTARY CAESAREAN SECTION, IN THE HOSPITAL MUNICIPAL BOLIVIANO HOLANDES OVER THE COURSE OF SEPTEMBER TO DECEMBER OF 2015

Introducción: Para la sintesis de tejidos existe diversidad de materiales, los más conocidos son los hilos de sutura (absorbible y no absorbible); sin embargo exisen otras alternativas de sutura, como son los adhesivos tisulares en base a cianoacrilato. Objetivo: Determinar la eficacia del cianoacrilato en el cierre de heridas de pacientes intervenidas mediante cesárea segmentaria en el servicio de Ginecología y Obstetricia del Hospital Municipal Bolivano Holandés durante la gesión 2015. Material y métodos: Ensayo clinico ciego simple, longitudinal, prospectivo . Se estudiaron 82 pacientes de 16 a 45 años de edad, internadas en el servicio de Ginecología y Obstetricia del Hospital Municipal Boliviano Holandés, durante el periodo del 1° de Septiembre hasta el 31 de Diciembre del año 2015. Se congregaron en 2 grupos: 34 pacientes en las que se empleo el cianoacrilato (caso) y 48 pacientes en las que se realizó la técnica de sutura intradérminac on nylon 3-0 (control), para posteriormente valorar el tiempo de cierre de la herida quirúrgica, reacción de la epidermis y complicaciones postoperatorias en cada grupo. Resultados: En cuanto al tiempo de cierre de la herida quirúrgica: 7 días con cianoacrilato(61.77%) y 7 días con nylon (77.08%); presencia de cicatriz hipertrofica: 0.00% con cianoacrilato y 4.17 % con nylon: y complicaciones 26.47% con cianoacrilato y 0.00 % con nylon. Conclusión: El cianoacrilato no es más eficaz que la sutura convencional en el cierre de heridas de pacientes intervenidas mediante cesárea segmentaria

Evaluación de la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes con síndrome coronario agudo: aplicación de un modelo de Markov probabilístico

[RESUMEN]. Objetivo. Evaluar la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes que presentaron un síndrome coronario agudo. Métodos. Se realizó una evaluación económica a partir de un estudio de intervención cuasi-experimental, que incluyó 442 pacientes con edades entre 30 y 70 años, quienes presentaron un síndrome coronario agudo. El grupo de intervención (n = 165) recibió un modelo integral de tratamiento ambulatorio fundamentado en el cuidado gestionado (disease management), mientras que el grupo control (n = 277) recibió rehabilitación cardiovascular convencional. Durante un año de seguimiento, se evaluó la presentación de reeventos cardiovasculares y hospitalizaciones. Se desarrolló un modelo de Markov probabilístico. La perspectiva de estudio se aplicó dentro del Sistema General de Seguridad Social en Salud Colombiano, incluidos los costos sanitarios directos; el horizonte temporal fue de 50 años con descuentos de 3,42% para costos y efectividades; y la medida de efectividad fue los años de vida ganados ajustados por calidad. Se realizó un análisis de sensibilidad probabilístico y multivariante mediante de la simulación de Montecarlo. Resultados. Durante el año de seguimiento, los costos directos relacionados con el valor pagado fueron en promedio de USD 2 577 para el grupo control y USD 2 245 para el grupo de intervención. En el análisis de sensibilidad probabilístico, 91,3% de las simulaciones se ubicaron en el cuadrante correspondiente a costos incrementales negativos y efectividades incrementales positivas (intervención evaluada de menor costo, más efectiva). En las simulaciones, se observó un ahorro promedio anual por paciente de USD 1 215 por cada año de vida ganado ajustado por calidad. Conclusiones. El modelo integral de tratamiento ambulatorio implementado en pacientes que sufrieron un síndrome coronario agudo mostró ser menos costoso y más efectivo en comparación con el cuidado convencional. Por ser una alternativa dominante, se recomienda como modelo de cuidado en esta población.

[ABSTRACT]. Objective. To evaluate the cost-effectiveness of an integral model of ambulatory treatment in patients who presented an acute coronary syndrome. Methods. An economic evaluation was made from a quasi-experimental intervention study, which included 442 patients aged 30 to 70 years who presented an acute coronary syndrome. The intervention group (n = 165) received an integral model of ambulatory treatment based on managed care (disease management), while the control group (n = 277) received conventional cardiovascular rehabilitation. During one year of follow-up, the presentation of cardiovascular events and hospitalizations was evaluated. A probabilistic Markov model was developed. The study perspective was applied within the General System of Health Social Security in Colombia, including the direct health costs; the time horizon was 50 years with discounts of 3.42% for costs and effectiveness; and the measure of effectiveness was quality-adjusted life years (QALYs). A probabilistic and multivariate sensitivity analysis was performed using the Montecarlo simulation. Results. During the year of follow-up, the direct costs related to the value paid were, on average, USD 2 577 for the control group and USD 2 245 for the intervention group. In the probabilistic sensitivity analysis, 91.3% of the simulations were located in the quadrant corresponding to incremental negative costs and positive incremental effectiveness (evaluated intervention at a lower cost, more effective). In the simulations, an average annual savings per patient of USD 1 215 per QALY was observed. Conclusions. The integral model of ambulatory treatment implemented in patients who suffered an acute coronary syndrome was found to be less expensive and more effective compared to conventional care. Considering it is a dominant alternative, it is recommended as a model of care in this population.

[RESUMO]. Objetivo. Avaliar a relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes que apresentaram síndrome coronariana aguda. Métodos. Uma avaliação econômica foi feita a partir de um estudo de intervenção quase experimental, que incluiu 442 pacientes com idade entre 30 a 70 anos que apresentaram síndrome coronariana aguda. O grupo de intervenção (n = 165) recebeu um modelo integral de tratamento ambulatorial com base em cuidados gerenciados (gerenciamento de doenças), enquanto o grupo controle (n = 277) recebeu reabilitação cardiovascular convencional. Durante um ano de acompanhamento, foi avaliada a apresentação de eventos cardiovasculares e hospitalizações. Um modelo probabilístico de Markov foi desenvolvido. A perspectiva do estudo foi aplicada no Sistema Geral de Segurança Social na Saúde da Colômbia, incluindo os custos diretos de saúde; o horizonte temporal foi de 50 anos com descontos de 3,42% em custos e efetividade; e a medida de eficácia foi os anos de vida ajustados pela qualidade (QALY). Uma análise de sensibilidade probabilística e multivariada foi realizada utilizando a simulação de Montecarlo. Resultados. Durante o ano de acompanhamento, os custos diretos relacionados ao valor pago foram, em média, USD 2 577 para o grupo controle e USD 2 245 para o grupo de intervenção. Na análise de sensibilidade probabilística, foram localizadas 91,3% das simulações no quadrante correspondente a custos negativos incrementais e eficácia incremental positiva (intervenção avaliada a menor custo, mais efetiva). Nas simulações, observou-se uma economia anual média por paciente de US $ 1 215 por QALY. Conclusões. O modelo integral de tratamento ambulatorial implementado em pacientes que sofreram síndrome coronariana aguda foi considerado menos caro e mais eficaz em comparação com os cuidados convencionais. Por ser uma alternativa dominante, é recomendado como modelo de cuidados nesta população.

[Evaluation of the cost-effectiveness of an integral model of ambulatory treatment in patients with acute coronary syndrome: application of a probabilistic Markov modelAvaliação da relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes com síndrome coronariana aguda: aplicação de um modelo probabilístico de Markov]. / Evaluación de la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes con síndrome coronario agudo: aplicación de un modelo de Markov probabilístico.

OBJECTIVE: To evaluate the cost-effectiveness of an integral model of ambulatory treatment in patients who presented an acute coronary syndrome. METHODS: An economic evaluation was made from a quasi-experimental intervention study, which included 442 patients aged 30 to 70 years who presented an acute coronary syndrome. The intervention group (n = 165) received an integral model of ambulatory treatment based on managed care (disease management), while the control group (n = 277) received conventional cardiovascular rehabilitation. During one year of follow-up, the presentation of cardiovascular events and hospitalizations was evaluated. A probabilistic Markov model was developed. The study perspective was applied within the General System of Health Social Security in Colombia, including the direct health costs; the time horizon was 50 years with discounts of 3.42% for costs and effectiveness; and the measure of effectiveness was quality-adjusted life years (QALYs). A probabilistic and multivariate sensitivity analysis was performed using the Montecarlo simulation. RESULTS: During the year of follow-up, the direct costs related to the value paid were, on average, USD 2 577 for the control group and USD 2 245 for the intervention group. In the probabilistic sensitivity analysis, 91.3% of the simulations were located in the quadrant corresponding to incremental negative costs and positive incremental effectiveness (evaluated intervention at a lower cost, more effective). In the simulations, an average annual savings per patient of USD 1 215 per QALY was observed. CONCLUSIONS: The integral model of ambulatory treatment implemented in patients who suffered an acute coronary syndrome was found to be less expensive and more effective compared to conventional care. Considering it is a dominant alternative, it is recommended as a model of care in this population.

OBJETIVO: Avaliar a relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes que apresentaram síndrome coronariana aguda. MÉTODOS: Uma avaliação econômica foi feita a partir de um estudo de intervenção quase experimental, que incluiu 442 pacientes com idade entre 30 a 70 anos que apresentaram síndrome coronariana aguda. O grupo de intervenção (n = 165) recebeu um modelo integral de tratamento ambulatorial com base em cuidados gerenciados (gerenciamento de doenças), enquanto o grupo controle (n = 277) recebeu reabilitação cardiovascular convencional. Durante um ano de acompanhamento, foi avaliada a apresentação de eventos cardiovasculares e hospitalizações. Um modelo probabilístico de Markov foi desenvolvido. A perspectiva do estudo foi aplicada no Sistema Geral de Segurança Social na Saúde da Colômbia, incluindo os custos diretos de saúde; o horizonte temporal foi de 50 anos com descontos de 3,42% em custos e efetividade; e a medida de eficácia foi os anos de vida ajustados pela qualidade (QALY). Uma análise de sensibilidade probabilística e multivariada foi realizada utilizando a simulação de Montecarlo. RESULTADOS: Durante o ano de acompanhamento, os custos diretos relacionados ao valor pago foram, em média, USD 2 577 para o grupo controle e USD 2 245 para o grupo de intervenção. Na análise de sensibilidade probabilística, foram localizadas 91,3% das simulações no quadrante correspondente a custos negativos incrementais e eficácia incremental positiva (intervenção avaliada a menor custo, mais efetiva). Nas simulações, observou-se uma economia anual média por paciente de US $ 1 215 por QALY. CONCLUSÕES: O modelo integral de tratamento ambulatorial implementado em pacientes que sofreram síndrome coronariana aguda foi considerado menos caro e mais eficaz em comparação com os cuidados convencionais. Por ser uma alternativa dominante, é recomendado como modelo de cuidados nesta população.

Evaluación de la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes con síndrome coronario agudo: aplicación de un modelo de Markov probabilístico / Evaluation of the cost-effectiveness of an integral model of ambulatory treatment in patients with acute coronary syndrome: application of a probabilistic Markov model / Avaliação da relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes com síndrome coronariana aguda: aplicação de um modelo probabilístico de Markov

RESUMEN Objetivo Evaluar la costo-efectividad de un modelo integral de tratamiento ambulatorio en pacientes que presentaron un síndrome coronario agudo. Métodos Se realizó una evaluación económica a partir de un estudio de intervención cuasi-experimental, que incluyó 442 pacientes con edades entre 30 y 70 años, quienes presentaron un síndrome coronario agudo. El grupo de intervención (n = 165) recibió un modelo integral de tratamiento ambulatorio fundamentado en el cuidado gestionado (disease management), mientras que el grupo control (n = 277) recibió rehabilitación cardiovascular convencional. Durante un año de seguimiento, se evaluó la presentación de reeventos cardiovasculares y hospitalizaciones. Se desarrolló un modelo de Markov probabilístico. La perspectiva de estudio se aplicó dentro del Sistema General de Seguridad Social en Salud Colombiano, incluidos los costos sanitarios directos; el horizonte temporal fue de 50 años con descuentos de 3,42% para costos y efectividades; y la medida de efectividad fue los años de vida ganados ajustados por calidad. Se realizó un análisis de sensibilidad probabilístico y multivariante mediante de la simulación de Montecarlo. Resultados Durante el año de seguimiento, los costos directos relacionados con el valor pagado fueron en promedio de USD 2 577 para el grupo control y USD 2 245 para el grupo de intervención. En el análisis de sensibilidad probabilístico, 91,3% de las simulaciones se ubicaron en el cuadrante correspondiente a costos incrementales negativos y efectividades incrementales positivas (intervención evaluada de menor costo, más efectiva). En las simulaciones, se observó un ahorro promedio anual por paciente de USD 1 215 por cada año de vida ganado ajustado por calidad. Conclusiones El modelo integral de tratamiento ambulatorio implementado en pacientes que sufrieron un síndrome coronario agudo mostró ser menos costoso y más efectivo en comparación con el cuidado convencional. Por ser una alternativa dominante, se recomienda como modelo de cuidado en esta población.

ABSTRACT Objective To evaluate the cost-effectiveness of an integral model of ambulatory treatment in patients who presented an acute coronary syndrome. Methods An economic evaluation was made from a quasi-experimental intervention study, which included 442 patients aged 30 to 70 years who presented an acute coronary syndrome. The intervention group (n = 165) received an integral model of ambulatory treatment based on managed care (disease management), while the control group (n = 277) received conventional cardiovascular rehabilitation. During one year of follow-up, the presentation of cardiovascular events and hospitalizations was evaluated. A probabilistic Markov model was developed. The study perspective was applied within the General System of Health Social Security in Colombia, including the direct health costs; the time horizon was 50 years with discounts of 3.42% for costs and effectiveness; and the measure of effectiveness was quality-adjusted life years (QALYs). A probabilistic and multivariate sensitivity analysis was performed using the Montecarlo simulation. Results During the year of follow-up, the direct costs related to the value paid were, on average, USD 2 577 for the control group and USD 2 245 for the intervention group. In the probabilistic sensitivity analysis, 91.3% of the simulations were located in the quadrant corresponding to incremental negative costs and positive incremental effectiveness (evaluated intervention at a lower cost, more effective). In the simulations, an average annual savings per patient of USD 1 215 per QALY was observed. Conclusions The integral model of ambulatory treatment implemented in patients who suffered an acute coronary syndrome was found to be less expensive and more effective compared to conventional care. Considering it is a dominant alternative, it is recommended as a model of care in this population.

RESUMO Objetivo Avaliar a relação custo-eficácia de um modelo integral de tratamento ambulatorial em pacientes que apresentaram síndrome coronariana aguda. Métodos Uma avaliação econômica foi feita a partir de um estudo de intervenção quase experimental, que incluiu 442 pacientes com idade entre 30 a 70 anos que apresentaram síndrome coronariana aguda. O grupo de intervenção (n = 165) recebeu um modelo integral de tratamento ambulatorial com base em cuidados gerenciados (gerenciamento de doenças), enquanto o grupo controle (n = 277) recebeu reabilitação cardiovascular convencional. Durante um ano de acompanhamento, foi avaliada a apresentação de eventos cardiovasculares e hospitalizações. Um modelo probabilístico de Markov foi desenvolvido. A perspectiva do estudo foi aplicada no Sistema Geral de Segurança Social na Saúde da Colômbia, incluindo os custos diretos de saúde; o horizonte temporal foi de 50 anos com descontos de 3,42% em custos e efetividade; e a medida de eficácia foi os anos de vida ajustados pela qualidade (QALY). Uma análise de sensibilidade probabilística e multivariada foi realizada utilizando a simulação de Montecarlo. Resultados Durante o ano de acompanhamento, os custos diretos relacionados ao valor pago foram, em média, USD 2 577 para o grupo controle e USD 2 245 para o grupo de intervenção. Na análise de sensibilidade probabilística, foram localizadas 91,3% das simulações no quadrante correspondente a custos negativos incrementais e eficácia incremental positiva (intervenção avaliada a menor custo, mais efetiva). Nas simulações, observou-se uma economia anual média por paciente de US $ 1 215 por QALY. Conclusões O modelo integral de tratamento ambulatorial implementado em pacientes que sofreram síndrome coronariana aguda foi considerado menos caro e mais eficaz em comparação com os cuidados convencionais. Por ser uma alternativa dominante, é recomendado como modelo de cuidados nesta população.

Caso Clínico: Quiste de Colédoco Tipo IA, Resolución Quirúrgica / Case Report: Type IA Choledochal Cyst, Surgical Resolution

INTRODUCCIÓN: El quiste del colédoco es una malformación congénita de etiología desconocida, caracterizada por diversos grados de dilatación del sistema biliar. El examen inicial para la valoración de la vía biliar debe ser una ecografía abdominal,sin embargo, la resonancia magnética con contraste es el estudio de elección para valorar estas estructuras. El tratamiento quirúrgico final depende del grado de dilatación quística y generalmente está basado en la escisión completa de la vía biliar extrahepática. CASO CLÍNICO: Paciente de sexo femenino de 27 años con dolor abdominal tipo cólico a nivel de epigastrio e hipocondrio derecho de 7 días de evolución. Se realizaron exámenes de Imagenología (ecografía­ TAC ­colangio RM)que reportaron colédoco con marcada dilatación fusiforme en toda su extensión, en relación a quiste de colédoco tipo IA. EVOLUCIÓN: Se planificó la exéresis del quiste de colédoco, anastomosis bilio-digestiva en «Y de Roux¼ y colecistectomía. El procedimiento quirúrgico no tuvo complicaciones. La paciente permaneció hospitalizada por 5 días con adecuada evolución y tolerancia a dieta. CONCLUSIÓN: El quiste de colédoco es una patología congénita infrecuente en la edad adulta generalmente diagnosticada como un hallazgo incidental. El diagnóstico y tratamiento oportuno aseguran el éxito del procedimiento quirúrgico y evita la aparición de complicaciones graves (colangiocarcinoma); con la escisión completa el pronóstico es excelente, la mortalidad posoperatoria es mínima. (au)

BACKGROUND: The choledochal cyst is a congenital malformation of unknown etiology characterized by different grades of dilatation of the biliary system. The first exam to evaluate the bile duct should be the abdominal ultrasound, which suggests the diagnosis of choledochal cyst. However, the magnetic resonance imagin with contrast is the gold standard to assess these structures. The final surgery treatment depends of the grade of cyst dilatation, the main procedure is based on the complete excision of the extrahepatic bile duct. CASE REPORT: A female 27-years old patient who reffered colic abdominal pain localized in epigastrium and right hypochondrium for 7 days. Imaging exams were performed (US­CT Scan­ choledochal MRI) which reported the bile duct with a severe fusiform dilatation, in complete extension related to type IA choledochal cyst. EVOLUTION: Choledocal cyst exeresis, «Roux-en-Y¼ bilio digestive anastomosis and cholecystectomy were planned. Surgical procedure had no complications. Patient was hospitalized for 5 days with proper evolution and oral diet tolerance. CONCLUSION: The choledochal cyst is a rare congenital disease in adult hood mostly diagnosed as an incidental finding. Early diagnosis and treatment ensure the success of the surgical procedure and prevents appearance of serious complications (cholangiocarcinoma).The prognosis after complete excision is excellent with minimal postoperative mortality(au)

Caso Clínico: Quiste de Uraco en un Paciente Adulto, Resolución Laparoscópica / Case Report: Urachal Cyst of an Adult Patient, Laparoscopic Resolution

INTRODUCCIÓN: La patología por remanente de uraco representa un fracaso en el proceso de obliteración, es una anomalía rara congénita que se diagnostica en el 1.6 % de los niños menores a 15 años y en el 0.063 % de los adultos. CASO CLÍNICO: Paciente de 42 años, sexo masculino, intervenido por laparoscopía por apendicitis aguda complicada. Durante el procedimiento se encontró una masa a nivel de la pared abdominal anterior en contacto con la vejiga. Mediante exámenes complementarios se diagnosticó quiste de uraco. EVOLUCIÓN: Se planificó la exéresis del quiste de uraco por vía laparoscópica, el procedimiento se realizó sin complicaciones obteniéndose un quiste de 6 x 4 cm de diámetro, remanante del ligamento umbilical. No fue necesaria la resección de la cúpula vesical. El posquirúrgico evolucionó de manera favorable y el paciente se mantuvo hospitalizado durante 2 días antes de ser dado de alta. CONCLUSIÓN: La resolución laparoscópica es una técnica segura y efectiva de elección para la exéresis del quiste del uraco en adultos. Presenta ventajas en relación a la cirugía convencional por la disminución del riesgo de infección del sitio quirúrgico, disminuye el dolor posquirúrgico, disminuye la estancia hospitalaria y permite la reincorporación laboral temprana.(au)

BACKGROUND: Remnant urachal pathology represents an obliteration failure, it is a rare congenital anomaly diagnosed in 1.6 % of under 15-years and 0.063 % of adult patients. CASE REPORT: A 42-years old male patient who underwent laparoscopic surgery because of an acute complicated appendicitis. During procedure, a mass was found near to anterior abdominal wall, it had contact with the urinary bladder's wall. Complementary exams were performed and an urachal cyst w pically and was found to be an incidental mass at the level of the anterior abdominal wall in acontact with the bladder. Urachal cyst was diagnosed based on complementary studies. EVOLUTION: Laparoscopic exeresis of the urachal cyst was planned. The procedure had no complications and a 6 x 4 cm urachal cyst was obtained (umbilical ligament remnant). Urinary bladder's dome resection was not required. The postoperative was favorable and the patient stood hospitalized for 2 days before he was discharged. CONCLUSION: Laparoscopic resolution is a safe and effective technique to perform an urachal cyst exeresis in adults. It has some advantages over conventional surgery as lower surgical site infection risk, less postoperative pain, shorter hospital stay and early return to work.(au)

Video. Caso Clínico. Cirugía Laparoscópica: Tratamiento Laparoscópico de Hernias Incisionales Ventrales / Case Report: Laparoscopic Surgery Video: Laparoscopic Treatment o Incisional Ventral Hernia

La patología herniaria ha captado la atención de los diferentes grupos quirúrgicos por su impacto en la frecuencia e incapacidad laboral, social y sus complicaciones relacionadas. Las hernias de pared abdominal se presentan con una frecuencia de entre 10 % y 15 % de la población general. La hernioplastia es una de las 2 principales intervenciones quirúrgicas electivas en los servicios de cirugía general. El desarrollo de nuevas técnicas de diagnóstico así como la creación de un gran número de materiales protésicos y accesorios para la fijación de los mismos, ha mejorado el tratamiento quirúrgico por laparoscopía.(AU)

The hernia pathology has captured the attention of the different surgical groups due to their impact on the frequency and incapacity of work, social and related complications. Abdominal wall hernias occur with a frequency of between 10 % and 15 % of the general population. Herniaplasty is one of the 2 main elective surgical interventions in general surgery services. The development of new diagnostic techniques as well as the creation of a large number of prosthetic materials and accessories to fix them, has improved the surgical treatment by laparoscopy.(AU)

Right hepatic artery aneurysm.

We report a case of an aneurysm of the right hepatic artery and its multidisciplinary management by general surgery, endoscopy and radiology services. Being a case of extremely low incidence, it is important to show its diagnostic and therapeutic approach. RESUMO Relatamos um caso de aneurisma da artéria hepática direita conduzido de forma multidisciplinar pelos Serviços de Cirurgia Geral, Endoscopia e Radiologia. Em se tratando de caso de incidência baixíssima, é importante mostrar o enfoque diagnóstico e terapêutico usado em seu manejo.

Steroidal Saponins from Furcraea hexapetala Leaves and Their Phytotoxic Activity.

Four new steroidal saponins (1-4) along with 13 known saponins were isolated from the leaves of Furcraea hexapetala. The new compounds were identified as (20R,22R,25R)-3ß-hydroxy-5α-spirostan-12-one 3-O-{α-l-rhamnopyranosyl-(1→4)-O-ß-d-glucopyranosyl-(1→3)-O-[ß-d-glucopyranosyl-(1→3)-O-ß-d-glucopyranosyl-(1→2)]-O-ß-d-glucopyranosyl-(1→4)-O-ß-d-galactopyranoside} (1), (25R)-3ß-hydroxy-5α-spirost-20(21)-en-12-one 3-O-{α-l-rhamnopyranosyl-(1→4)-O-ß-d-glucopyranosyl-(1→3)-O-[ß-d-glucopyranosyl-(1→3)-O-ß-d-glucopyranosyl-(1→2)]-O-ß-d-glucopyranosyl-(1→4)-O-ß-d-galactopyranoside} (2), (25R)-5α-spirostan-3ß-ol 3-O-{ß-d-glucopyranosyl-(1→2)-O-ß-d-glucopyranosyl-(1→2)-O-ß-d-glucopyranosyl-(1→4)-O-ß-d-galactopyranoside} (3), and (25R)-5ß-spirostan-3ß-ol 3-O-{ß-d-glucopyranosyl-(1→6)-O-ß-d-galactopyranoside} (4) by spectroscopic analysis, including one- and two-dimensional NMR techniques, mass spectrometry, and chemical methods. The phytotoxicity of the isolated compounds against the standard target species Lactuca sativa was evaluated. Structure-activity relationships for these compounds with respect to phytotoxic effects are discussed.

Right hepatic artery aneurysm / Aneurisma de artéria hepática direita

ABSTRACT We report a case of an aneurysm of the right hepatic artery and its multidisciplinary management by general surgery, endoscopy and radiology services. Being a case of extremely low incidence, it is important to show its diagnostic and therapeutic approach.

RESUMO Relatamos um caso de aneurisma da artéria hepática direita conduzido de forma multidisciplinar pelos Serviços de Cirurgia Geral, Endoscopia e Radiologia. Em se tratando de caso de incidência baixíssima, é importante mostrar o enfoque diagnóstico e terapêutico usado em seu manejo.

Dipstick Spot urine pH does not accurately represent 24 hour urine PH measured by an electrode.

OBJECTIVES: To determine whether spot urine pH measured by dipstick is an accurate representation of 24 hours urine pH measured by an electrode. MATERIALS AND METHODS: We retrospectively reviewed urine pH results of patients who presented to the urology stone clinic. For each patient we recorded the most recente pH result measured by dipstick from a spot urine sample that preceded the result of a 24-hour urine pH measured by the use of a pH electrode. Patients were excluded if there was a change in medications or dietary recommendations or if the two samples were more than 4 months apart. A difference of more than 0.5 pH was considered na inaccurate result. RESULTS: A total 600 patients were retrospectively reviewed for the pH results. The mean difference in pH between spot urine value and the 24 hours collection values was 0.52±0.45 pH. Higher pH was associated with lower accuracy (p<0.001). The accuracy of spot urine samples to predict 24-hour pH values of <5.5 was 68.9%, 68.2% for 5.5 to 6.5 and 35% for >6.5. Samples taken more than 75 days apart had only 49% the accuracy of more recent samples (p<0.002). The overall accuracy is lower than 80% (p<0.001). Influence of diurnal variation was not significant (p=0.588). CONCLUSIONS: Spot urine pH by dipstick is not an accurate method for evaluation of the patients with urolithiasis. Patients with alkaline urine are more prone to error with reliance on spot urine pH.

Dipstick spot urine pH does not accurately represent 24 hour urine PH measured by an electrode

ABSTRACT Objectives To determine whether spot urine pH measured by dipstick is an accurate representation of 24 hours urine pH measured by an electrode. Materials and Methods We retrospectively reviewed urine pH results of patients who presented to the urology stone clinic. For each patient we recorded the most recent pH result measured by dipstick from a spot urine sample that preceded the result of a 24-hour urine pH measured by the use of a pH electrode. Patients were excluded if there was a change in medications or dietary recommendations or if the two samples were more than 4 months apart. A difference of more than 0.5 pH was considered an inaccurate result. Results A total 600 patients were retrospectively reviewed for the pH results. The mean difference in pH between spot urine value and the 24 hours collection values was 0.52±0.45 pH. Higher pH was associated with lower accuracy (p<0.001). The accuracy of spot urine samples to predict 24-hour pH values of <5.5 was 68.9%, 68.2% for 5.5 to 6.5 and 35% for >6.5. Samples taken more than 75 days apart had only 49% the accuracy of more recent samples (p<0.002). The overall accuracy is lower than 80% (p<0.001). Influence of diurnal variation was not significant (p=0.588). Conclusions Spot urine pH by dipstick is not an accurate method for evaluation of the patients with urolithiasis. Patients with alkaline urine are more prone to error with reliance on spot urine pH.