Effect of biomolecules derived from human platelet-rich plasma on the ex vivo expansion of human adipose-derived mesenchymal stem cells for clinical applications.

Mesenchymal stem cells are a tool in cell therapies but demand a large cell number per treatment, for that, suitable culture media is required which contains fetal bovine serum (FBS). However, for cell-based therapy applications, the use of FBS is problematic. Several alternatives to FBS have been explored, including human derivatives from platelet-rich plasma (hD-PRP). Although various studies have evaluated the impact of hD-PRP on MSC proliferation and differentiation, few of them have assessed their influence on processes, such as metabolism and gene expression. Here, we cultured human adipose-derived MSCs (hAD-MSCs) in media supplemented with either 10% hD-PRP (hD-PRP-SM) or 10% FBS (FBS-SM) in order to characterize them and evaluate the effect of hD-PRP on cell metabolism, gene expression of associated regenerative factors, as well as chromosome stability during cell expansion. We found that hAD-MSCs cultured in hD-PRP-SM have a greater cell elongation but express similar surface markers; in addition, hD-PRP-SM promoted a significant osteogenic differentiation in the absence of differentiation medium and increased the growth rate, maintaining chromosomal stability. In terms of cell metabolic profile, hAD-MSC behavior did not reveal any differences between both culture conditions. Conversely, significant differences in collagen I and angiopoietin 2 expression were observed between both conditions. The present results suggest that hD-PRP may influence hAD-MSC behavior.

Tratamiento de malformaciones y tumores vasculares, en un centro de referencia en Bogotá / Treatment of vascular malformations and tumors in a reference center in Bogotá

Introducción. Las malformaciones vasculares son anomalías que están presentes desde el nacimiento, no desaparecen y pueden crecer a lo largo de la vida. Se ha demostrado en estudios retrospectivos que la terminología para clasificar las anomalías vasculares es inexacta en un 69 % de casos, por lo que se hace un diagnostico inadecuado y en un 53 % de casos se brinda al paciente y su familia una información incorrecta del tratamiento y el curso clínico. Métodos. Estudio prospectivo longitudinal, realizado entre 2016 y 2019, donde se incluyeron pacientes con anomalías vasculares, que consultaron a nuestra institución, fueron valorados por el servicio de cirugía vascular, se hizo un plan diagnóstico y manejo integral, vía endovascular, quirúrgica o mixta, de acuerdo con cada caso. Resultados. La malformación más común fue la de tipo venoso, en el 40,3 % de los casos. Se realizó manejo endovascular en el 93,1 % de casos de malformaciones vasculares y quirúrgico en el 6,9 %. La mejoría de los síntomas que motivaron la consulta fue del 100 % para los tumores vasculares y del 70,8 % para las malformaciones. Sin embargo, los resultados son heterogéneos. Discusión. Es necesario realizar un adecuado diagnóstico de las anomalías vasculares, para alcanzar un trata-miento eficaz, con mejoría de los síntomas

Introduction. Vascular malformations are abnormalities that are present from birth, do not disappear and can grow throughout life. It has been shown in retrospective studies that the terminology to classify vascular anomalies is inaccurate in 69% of cases, an inappropriate diagnosis is made and in 53% of cases the patient and their family are given incorrect information on the treatment and the clinical course.Methods. Longitudinal prospective study conducted between 2016 and 2019. Patients with vascular anomalies and consulted to our institution were included. They were evaluated by the vascular surgery service, and a comprehensive diagnosis and management plan was made, including endovascular, surgical or mixed, according to each case. Results. The most common malformation was the venous type in 40.3% of the cases. Endovascular management was performed in 93.1% of cases and surgery in 6.9%. The improvement in the symptoms that led to the con-sultation was 100% for vascular tumors and 70.8% for malformations. However, the results are heterogeneous.Conclusions. It is necessary to obtain an adequate diagnosis of vascular anomalies, to achieve an effective treatment, with improvement of the symptoms

Solving the negative impact of congestion in the postanesthesia care unit: a cost of opportunity analysis.

BACKGROUND: Congestion in the postanesthesia care unit (PACU) leads to the formation of waiting queues for patients being transferred after surgery, negatively affecting hospital resources. As patients recover in the operating room, incoming surgeries are delayed. The purpose of this study was to establish the impact of this phenomenon in multiple settings. METHODS: An operational mathematical study based on the queuing theory was performed. Average queue length, average queue waiting time, and daily queue waiting time were evaluated. Calculations were based on the mean patient daily flow, PACU length of stay, occupation, and current number of beds. Data was prospectively collected during a period of 2 months, and the entry and exit time was recorded for each patient taken to the PACU. Data was imputed in a computational model made with MS Excel. To account for data uncertainty, deterministic and probabilistic sensitivity analyses for all dependent variables were performed. RESULTS: With a mean patient daily flow of 40.3 and an average PACU length of stay of 4 hours, average total lost surgical opportunity time was estimated at 2.36 hours (95% CI: 0.36-4.74 hours). Cost of opportunity was calculated at $1592 per lost hour. Sensitivity analysis showed that an increase of two beds is required to solve the queue formation. CONCLUSIONS: When congestion has a negative impact on cost of opportunity in the surgical setting, queuing analysis grants definitive actions to solve the problem, improving quality of service and resource utilization.

Cost-effectiveness of kidney transplantation compared with chronic dialysis in end-stage renal disease.

To estimate the costs and effectiveness measured in quality-adjusted life years (QALY) of kidney transplantation compared with dialysis in adults suffering from end-stage renal disease from the perspective of the Colombian healthcare system, we designed a Markov model with monthly cycles over a five-year time horizon and eight transitional states, including death as an absorbing state. Transition probabilities were obtained from international registries, costs from different local sources [case studies, official tariffs (ISS 2001 + 35%) for procedures and SISMED for medications]. Data were validated by an expert panel and we performed univariate, multivariate and probabilistic sensitivity analyses. Effectiveness indicators were months of life gained, months of dialysis averted and deaths prevented. The annual discount rate was 3% and the cost-utility threshold (willingness to pay) was three times gross domestic product (GDP) = USD 20,000 per QALY. The costs were adopted in US dollars (USD) using the 2012 average exchange rate (1 USD = COP$ 1798). The discounted average total cost for five years was USD 76,718 for transplantation and USD 76,891 for dialysis, with utilities 2.98 and 2.10 QALY, respectively. Additionally, renal transplantation represented 6.9 months gained, 35 months in dialysis averted per patient and one death averted for each of the five patients transplanted in five years. We conclude that renal transplantation improves the overall survival rates and quality of life and is a cost-saving alternative compared with dialysis.

Implicaciones y costo-efectividad del alta temprana del binomio madre-hijo después de un parto normal / Implications and cost-effectiveness of early discharge of the mother-child pair after normal parturition

Introducción: Se revisó la literatura internacional sobre alta temprana (24-48 horas) y su relación con complicaciones, para elaborar un modelo de costo-efectividad en recién nacidos, por parto vaginal a término no complicado, comparándola con ultratemprana (<24 horas) que incluya un programa de control posnatal organizado que permita evaluar a la madre y al bebe a las 48- 72 horas. Materiales y métodos: Se diseñó un árbol de decisión para un hospital que preste servicio de obstetricia, desde la perspectiva del sistema de salud colombiano. El horizonte de tiempo fue el periodo neonatal (primer mes de vida extrauterina). La efectividad fue medida en los siguientes desenlaces: reconsultas evitadas y hospitalizaciones evitadas. Resultados: Se estima que cada año nacen 336.000 niños por partos vaginales a término. Cada día de reducción de estancia hospitalaria implicaría 29 mil millones de pesos de ahorro para el sistema de salud colombiano. Comparada con el alta temprana ($88.015) el alta ultratemprana cuesta más ($93.129) y se asocia con una mayor tasa de hospitalización (55 incrementales por cada 1000) y de reconsultas (320 adicionales por cada 1000). Conclusión: Un alta ultratemprana se justifi caría solo si se cumpliera con una detallada lista de chequeo para garantizar que el ahorro para el sistema no se traduzca en mayores complicaciones para la madre y el niño.

Introduction: We reviewed international literature on early discharge (24-48 hours), and its relationship with complications, to develop a cost-effectiveness model in normal uncomplicated vaginally delivered newborns, compared with "ultra-early" discharge (<24 hours) which includes an organized postnatal program to assess the mother and the baby at 48-72 hours. Materials and Methods: A decision tree model was designed for a hospital providing obstetrical service, from the perspective of the Colombian health system. The time horizon was the neonatal period (fi rst month after birth). Effectiveness was measured in the following outcomes: reconsultations avoided and hospitalizations avoided. Results: It is estimated that each year 336.000 children are born at term vaginal deliveries. Each day reduction in hospital means 29 billion pesos in savings for the health system in Colombia. Compared with early discharge ($ 88.015), "ultra-early" discharge costs more ($ 93.129) and is associated with a higher rate of hospitalizations (55 more per 1000) and reconsultations (320 more per 1.000). Conclusion: "ultra-early" discharge could be justifi ed only if the hospital complies with a detailed checklist to ensure that the savings to the system do not result in major complications for mother or child.

Análisis de costos de atención de infarto cerebral agudo con o sin fibrilación auricular / Cost analysis of acute stroke care with or without atrial fibrillation

Objetivo. Estimar los costos totales y los componentes del costo de la atención hospitalaria en una serie de pacientes con infarto cerebral agudo (ICA) de gran vaso tratados en el Hospital Universitario San Ignacio, comparando aquellos con y sin fibrilación auricular (FA). Materiales y métodos. Se recogió una muestra secuencial de pacientes mayores de 50 años entre diciembre de 2010 y marzo de 2013. Para un análisis separado, se realizó un pareamiento por edad y NIHSS de ingreso en proporción 1:1 de pacientes con y sin FA. A todos los pacientes se les registró: edad, sexo, NIHSS de ingreso y egreso, Rankin modificado, y puntaje de CHAD2S2 VASC. En cada paciente se cuantificó el uso de recursos intrahospitalarios así como el costo total de la atención durante el evento agudo, calculado en pesos colombianos. Resultados. Se recogió información de 166 pacientes (125 sin y 41 con FA). El costo total promedio de la atención fue de $8.635.419 (DE $12.929.905). Este valor fue de $10.341.065 (DE $15.130.716) para los pacientes con FA y $8.056.718 (DE $12.114.840) para los pacientes sin FA. Conclusiones. A pesar de un costo de tratamiento mayor en pacientes con FA, que son de mayor edad y tienen infartos cerebrales más severos, la diferencia no fue estadísticamente significativa cuando se ajustó por edad y por severidad del compromiso neurológico.

Objective. To estimate the total costs and resource use of hospital care in a series of patients with large vessel ischemic stroke treated at the Hospital Universitario San Ignacio. Material and methods. Prospective convenience sample of all patients 50 years of age or older admitted between December 2010 and March 2013 diagnosed with ischemic stroke. Patients with and without atrial fibrillation (AF) were compared. The following variables were measured: age, sex, admission and discharge NIHSS, modified Rankin, and CHA2DS2 VASC score. We also quantified inpatient resource use and total cost of care during the acute event. Results. We analyzed 166 patients, 125 without non-valvular AF and 41 with non-valvular AF. For a separate analysis, we matched patients with and without AF (37 per group) by age and initial NIHSS, in a 1:1 ratio. The average total cost of care in Colombian pesos (as of February 2012, 1 US$= COP$1,805) for all stroke patients was $8,635,419 (SD $12,929,905). This value was $10,341,065 (SD $15,130,716) for patients with AF and $8,056,718 (SD $12,114,840) for patients without AF. Conclusions. Despite higher treatment cost in patients with AF, these are older and severe strokes. The difference is reduced and does not reach statistical significance, when adjusted for age and stroke severity.

The history and evolution of the clinical effectiveness of haemophilia type a treatment: a systematic review.

First evidence of cases of haemophilia dates from ancient Egypt, but it was when Queen Victoria from England in the 19th century transmitted this illness to her descendants, when it became known as the "royal disease". Last decades of the 20th century account for major discoveries that improved the life expectancy and quality of life of these patients. The history and evolution of haemophilia healthcare counts ups and downs. The introduction of prophylactic schemes during the 1970s have proved to be more effective that the classic on-demand replacement of clotting factors, nevertheless many patients managed with frequent plasma transfusions or derived products became infected with the Human Immunodeficiency Virus (HIV) and Hepatitis C virus during the 1980s and 1990s. Recombinant factor VIII inception has decreased the risk of blood borne infections and restored back longer life expectancies. Main concerns for haemophilia healthcare are shifting from the pure clinical aspects to the economic considerations of long-term replacement therapy. Nowadays researchers' attention has been placed on the future costs and cost-effectiveness of costly long-term treatment. Equity considerations are relevant as well, and alternative options for less affluent countries are under the scope of further research. The aim of this review was to assess the evidence of different treatment options for haemophilia type A over the past four decades, focusing on the most important technological advances that have influenced the natural course of this "royal disease".

Economic Evaluation of Four Drug Administration Systems in Intensive Care Units in Colombia.

INTRODUCTION: Intensive care units (ICUs) are the most frequent setting for serious medical errors, which not only have serious health consequences but also an economic impact. In this article, using a theoretical model, we evaluate four medication administration systems: conventional preparation by nursing staff, MINIBAG Plus delivery system, compounding center preparation, and premix drugs. METHODS: We designed a decision tree model from a third-party payer perspective, and the time horizon of the acute event. Local costs, in Colombian pesos (US $1 = 1784 COP$), were obtained from tariff manuals, medication costs from Sismed information system, and clinical variables from the published literature, and uncertainty was dealt with by an expert panel. The drug used for the model was dopamine. RESULTS: Average costs for each dopamine dose delivered were $46,995 for premix, $47,625 for compounding center, $101,934 for MINIBAG Plus, and $108,870 for drug prepared in the ICU. The variability of these results is higher for compounding center than for premix, and even higher for MINIBAG Plus and nurse delivery. CONCLUSIONS: The use of premix drugs can be a cost-saving strategy, which decreases medical errors in drug administration in the ICU, particularly if it is part of an integral error reduction program.

Estudio MULATA: muestra latinoamericana de pacientes con tensión arterial elevada / MULATA study: Latin American sample of high blood pressure patients

Introducción: Por prevalencia y trascendencia como factor de riesgo para enfermedad cardiovascular, la hipertensión arterial es una de las enfermedades de mayor importancia en la práctica médica. Este trabajo describe las características clínicas y sociodemográficas de una muestra de pacientes hipertensos con al menos un factor de riesgo cardiovascular adicional, en Argentina, Colombia y Venezuela. Metodología: Es un estudio de corte transversal, con recolección prospectiva de la información en una muestra por conveniencia de pacientes con hipertensión arterial que consultaron a los médicos participantes en cada uno de los tres países. Resultados: Se detectaron diferencias estadísticamente significativas en la distribución de los factores de riesgo cardiovascular (obesidad central, hipertensión arterial no controlada, tabaquismo y dislipidemia) entre las poblaciones de Colombia, Venezuela y Argentina. La población participante estuvo compuesta en su mayoría por mujeres (53,7%), la edad promedio fue de 59,3 +/- DE 13,6 años; 29% de los participantes en el estudio tenían cifras tensionales controladas en el momento de la evaluación. El manejo con dos medicamentos fue el más frecuente en la población total (40,6%) así como en los subgrupos, argentino (47,1%) y colombiano (46,4%), mientras que en la población venezolana el manejo más común fue monoterapia (45%). Los bloqueadores del sistema renina angiotensina II fueron los más utilizados en los tres países. Discusión: Los factores de riesgo cardiovascular susceptibles de ser modificados tienen diferencias geográficas que justifican cambios en su manejo. La hipertensión requiere no solamente manejo farmacológico, sino la intervención sobre estos factores.

Introduction: Due to its high prevalence and its importance as a risk factor for stroke, heart disease, and renal failure, hypertension is one of the most important diseases in common medical practice. The aim of this study was to describe the clinical and demographic characteristics of a sample of hypertensive patients, with at least one additional cardiovascular risk factor, in Argentina, Colombia and Venezuela. Methods: We performed a cross sectional study, with prospective data collection from a convenience sample of patients. Results: we found statistically significant differences in the distribution of cardiovascular risk factors (obesity, non-controlled hypertension, smoking and dyslipidemia) in the population of the different countries. There were slightly more women in our sample (53.7%), the average age was 59.3 (SD 13.6) years. In 29% of the patients hypertension was controlled. The most common practice in the whole sample was the use of two different drugs (40.6%). This was true both in Colombia (46.4%) and in Argentina (47.1%), while in Venezuela the use of monotherapy was more common (45%). Angiotensin II receptor antagonists are the most commonly used drug family in the three countries, either alone or in combination with other therapies. Discussion: Our population shows a poor control of blood pressure. Our patients need a more strict pharmacological therapy together with a strategy to identify and reduce all modifiable cardiovascular risk factors.

Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial.

INTRODUCTION: Our aim was to evaluate the impact of hyperproteic hypocaloric enteral feeding on clinical outcomes in critically ill patients, particularly on severity of organic failure measured with the Sequential Organ Failure Assessment (SOFA). MATERIALS AND METHODS: In a double blind clinical trial, 80 critically ill adult patients were randomized to hyperproteic hypocaloric or to isocaloric enteral nutrition; all patients completed follow-up of at least 4 days. Prescribed caloric intake was: Hyperproteic hypocaloric enteral nutrition (15 kcal/kg with 1.7 g/kg of protein) or isocaloric enteral nutrition (25 kcal/kg with 20% of the calories as protein). The main outcome was the differences in delta SOFA at 48 h. Secondary outcomes were intensive care unit (ICU) length of stay, days on ventilator, hyperglycemic events, and insulin requirements. RESULTS: There were no differences in SOFA score at baseline (7.5 (standard deviation (SD) 2.9) vs 6.7 (SD 2.5) P = 0.17). The total amount of calories delivered was similarly low in both groups (12 kcal/kg in intervention group vs 14 kcal/kg in controls), but proteic delivery was significantly different (1.4 vs 0.76 g/kg, respectively P ≤ 0.0001). The intervention group showed an improvement in SOFA score at 48 h (delta SOFA 1.7 (SD 1.9) vs 0.7 (SD 2.8) P = 0.04) and less hyperglycemic episodes per day (1.0 (SD 1.3) vs 1.7 (SD 2.5) P = 0.017). DISCUSSION: Enteral hyperproteic hypocaloric nutrition therapy could be associated with a decrease in multiple organ failure measured with SOFA score. We also found decreased hyperglycemia and a trend towards less mechanical ventilation days and ICU length of stay.

Burden of pneumococcal infection in adults in Colombia.

INTRODUCTION: The burden of Streptococcus pneumoniae infections is highest in children. Estimates in adult population are uncommon. We determined the burden of disease associated with pneumococcus in adults in Colombia in year 2008. METHODOLOGY: Using different data sources (official mortality records, medical databases, published literature and local epidemiological data) we estimated prevalence, incidence, mortality and disability due to bacterial pneumonia, bacterial meningitis and bacteremia of any cause for year 2008, and the fraction of these that can be attributed to S. pneumoniae. RESULTS: A total of 63,463 DALYs are lost due to S. pneumoniae in Colombians age 15 or over. Most of this burden (51,848 DALYs, 81.7%) is due to pneumonia, followed by meningitis (9241 DALYs, 14.6%). The three conditions, overall, represent 2.03 DALYs per 1000 Colombians in that age range. CONCLUSIONS: Despite the lower incidence of pneumococcal disease in adults, as compared with children, its burden is still significant, comparable to that of schizophrenia or epilepsy. This study may provide a benchmark for future preventive interventions.

Pacemaker implantation site neuralgia treated with lidocaine patches: case report / Neuralgia en el sitio de implantación de un marcapasos tratada con parches de lidocaína: reporte de caso

La neuralgia luego de la implantación de un marcapasos es una complicación rara que, muchas veces, requiere manejo quirúrgico. La etiología es desconocida; sin embargo, se han postulado diferentes teorías. Este artículo describe un caso exitoso de manejo médico con parche de lidocaína, y se hace una revisión del tema...

Severe chronic pacemaker pocket pain neuralgia is a rare complication of implanted pacemakers, and may require surgical management. Etiology of this disease is unknown, many theories, however, have been postulated. This paper analyzes onesuccessful case, managed with lidocaine patches, and reviews the literature...

Ethical and economic considerations of rare diseases in ethnic minorities: the case of mucopolysaccharidosis VI in Colombia.

Mucopolysaccharidosis VI is an autosomal recessive lysosomal storage disorder associated with severe disability and premature death. The presence of a mucopolysaccharidosis-like disease in indigenous ethnic groups in Colombia can be inferred from archaeological findings. There are several indigenous patients with mucopolysaccharidosis VI currently receiving enzyme replacement therapy. We discuss the ethical and economic considerations, regarding both direct and indirect costs, of a high-cost orphan disease in a marginalised minority population in a developing country.

Análisis de impacto presupuestal de la introducción de fingolimod en el tratamiento de esclerosis múltiple en Colombia: a budget impact analysis / Introduction of fingolimod for the treatment of multiple sclerosis in Colombia

La esclerosis múltiple está asociada con discapacidad a largo plazo y un significativo impacto social. La introducción de fingolimod, un medicamento eficaz en la reducción de recaídas, en comparación con interferon beta 1a, justifica un análisis de impacto presupuestal desde la perspectiva del sistema de salud colombiano. OBJETIVO: desarrollar un análisis de impacto presupuestal, para los años 2012 a 2016 de la introducción de fingolimod en el sistema de salud de Colombia. MATERIALES Y MÉTODOS: usando la perspectiva del sistema de salud, se diseñó un modelo de impacto presupuestal para determinar el efecto que la introducción del fingolimod para el tratamiento de pacientes con esclerosis múltiple remitente recurrente tendría sobre los recursos del sistema de salud. La información clínica y de prevalencia fue obtenidas de la literatura, los costos fueron tomados de registros hospitalarios. Se realizó una simulación de Monte Carlo como parte del análisis de sensibilidad. RESULTADOS: el costo neto anual (2012-2016) para el escenario sin fingolimod fue, en miles de millones de pesos, $20,96, $22,29, $23,37, $24,68, y $25,98. En el escenario con fingolimod el costo neto fue: $21,01, $22,42, $23,50, $24,91 y $26,39. Por otro lado, fingolimod se asoció con 91 recaídas evitadas en este periodo de cinco años. La simulación de Monte Carlo no mostró diferencias significativas de los costos entre los dos escenarios. CONCLUSIÓN: considerando estos supuestos, la introducción de fingolimod en el sistema de salud colombiano no implica un impacto presupuestal significativo, y representa una importante reducción en el número de recaídas prevenidas.

INTRODUCTION: multiple sclerosis (MS) is associated with long-term disability and significant social impact. First-line disease modifying treatments for MS (interferons and glatiramer acetate) have moderate efficacy and must be administered in daily or weekly injections. The introduction of fingolimod, a molecule with superior efficacy in reducing MS relapses compared to interferon-beta 1a justifies a budget impact analysis from a Colombian health system perspective. OBJETIVES: to develop a budget impact analysis, for years 2012 to 2016, of the introduction of fingolimod in the Colombian health system. MATERIALS AND METHODS: using the perspective of the Colombian health system, we designed a budget impact model to determine the effect that the introduction of fingolimod for patients with relapsing-remitting MS would have on the resources of the health system. Clinical data and prevalence were obtained from published literature, costs were collected from local sources. A Monte Carlo simulation was done as part of the sensitivity analysis. Exchange rate used was 2,565 pesos per euro (July 2011). RESULTS: total annual net costs (2012-2016) for the scenario without fingolimod were, in million euros, €8.17, €€8.69, €9.11, €9.62, and €10.13. In the fingolimod scenario net costs were: €8.19, €8.74, €9.16, €9.71 and €10.29. On the other hand, fingolimod was associated with 91 relapses averted in this five-year period. Monte Carlo simulation does not show relevant differences in costs between both scenarios. CONCLUSION: under these assumptions, the introduction of fingolimod in Colombian health care system does not imply a significant budget impact but represents an important reduction in the number MS relapses.

Perforación intestinal por espina de pescado, revisión de la literatura científica y presentación de dos casos: literature review and report of two cases / Intestinal perforation by fish bone

La presentación clínica de las perforaciones intestinales secundarias a la ingestión involuntaria de espinas de pescado suele ser inespecífica, lo que hace difícil su diagnóstico. Por tratarse de un cuadro clínico relativamente frecuente y potencialmente fatal, es necesario establecer un diagnóstico temprano y una terapia quirúrgica inmediata. En este artículo se hace una revisión de la literatura y se presentan dos casos clínicos de perforación intestinal por espina de pescado atendidos en el Hospital Universitario San Ignacio. El propósito de este trabajo es revisar la literatura y reportar dos casos tratados en el Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia.

The clinical presentation of an intestinal perforation secondary to involuntary ingestion of a fish bone tends to be nonspecific, making the diagnosis difficult. Nevertheless, the high frequency of this clinical entity, which undiagnosed may be fatal, makes it necessary to establish prompt diagnosis and treatment. Our objective in this paper is to review the literature and report two cases managed at Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia.

El deseo de muerte y el suicidio en la cultura occidental: parte 1: la edad antigua / Desire of death and suicide in western culture: part 1: ancient history

La ideación suicida debe ser tan antigua como la existencia humana. Los primeros textos abundan en referencias a los actos suicidas o a los claros deseos de muerte. La Biblia, por ejemplo, registra una decena de suicidios, desde el de Abimelec, en el libro de Jueces, hasta el de Judas Iscariote, en el evangelio de Mateo. No era raro el suicidio en la antigua Grecia o en el Imperio Romano, según se desprende de los textos de Heródoto o las Vidas paralelas, de Plutarco. Los mitos griegos, los poemas homéricos y las tragedias de Sófocles y de Eurípides nos ilustran también sobre las prácticas suicidas, las ideas de muerte y las actitudes sociales hacia la muerte por la propia mano. Este trabajo pretende explorar estos temas y hacer un recuento de los más reconocidos suicidas de la Edad Antigua...

Suicidal ideation may be as old as human existence. The first written records have plenty of references to suicidal acts and the desire to die. The Bible for example, records ten or so suicides beginning with Abimelech in the Book of Judges, to the suicidal act of Judas scariot in Matthew’s Gospel. Suicide was not unusual in Ancient Greece or the Roman Empire, as noted in Herodotus’ History or Plutarch’s Parallel Lives. Greek myths, Homeric poems, and the tragedies of Sophocles and Euripides are rich in suicidal practices, ideas of death, and discussions of social attitudes about killing one self. This paper explores these topics and collects the most important suicides of Old Age...

Evaluación económica del tratamiento de artritis reumatoide con terapia biológica anti TNF en Colombia / Economic evaluation of the treatment of rheumatoid arthritis with anti-TNF biological therapy in Colombia

Introducción: la artritis reumatoide (AR) es una enfermedad crónica de alto costo para el sistema de salud, en particular cuando se requiere terapia biológica. Objetivos: diseñar un modelo económico para la toma de decisiones entre adalimumab (ADA), etanercept (ETA) e infliximab (INF) en el contexto colombiano. Metodología: se diseñó un modelo de Markov, con un horizonte temporal de dos años, una perspectiva de un tercero pagador, que midiera efectividad clínica (en proporción de pacientes con respuesta ACR50 o mayor), abandono de terapia, eventos adversos, calidad de vida en AVAC (años de vida ajustados por calidad) y costos directos de tratamiento en pesos colombianos. Resultados: la suspensión de la terapia fue mayor para INF y menor para ETA. La ganancia en AVAC fue ligeramente más alta para ETA y para ADA que para INF. Los costos anuales promedio de la terapia con INF fueron $44.8 millones, para ADA $41.0 millones, y $39.0 millones para ETA. El costo promedio por mes logrado en ACR50 o superior fue de $9.37; $8.83 y $13.5 millones, respectivamente, para ADA, ETA e INF. Conclusiones: dadas las limitaciones y los supuestos del modelo, se podría concluir que, en el paciente colombiano "caso tipo" con AR, ETA es dominante sobre ADA e INF al tener un costo global total menor, y una efectividad superior a INF y por lo menos igual a la de ADA (Acta Med Colomb 2011; 36: 24-29).

Introduction: rheumatoid arthritis (RA) is a chronic illness that implies high direct and indirect costs for the health system, in particular when biological therapy is prescribed. Objectives: the aim of this study was to design an economic model for decision-making between adalimumab (ADA), etanercept (ETA) and infliximab (INF) in the Colombian context. Methods: we designed a Markov model with a time horizon of two years and a third party payer perspective, measuring the effectiveness (as proportion of patients with ACR50 response or better) discontinuation of therapy, adverse events, quality of life in QALY (quality adjusted life years) and direct cost represented in Colombian pesos (1 US$ = Col$1800 pesos, aprox). Results: discontinuation of therapy was highest for INF, and lowest for ETA. The gain in QALYs was somewhat higher for ETA and ADA, compared with INF. The total annual costs of the therapy with INF was $44.8 million, $41.0 million for ADA, and $39.0 for ETA. The cost per month with ACR50 or higher was $9.37; $8.83 and $13.5 million, respectively for ADA, ETA and INF. Conclusion: given the limitations and given the assumptions of this model, we conclude that in the average Colombian patient with AR, ETA is dominant over ADA and INF, by having a lower total cost and at least the same effectiveness as ADA and higher than INF (Acta Med Colomb 2011; 36: 24-29).