¿Es justificable el reintegro del gasto en enfermos quirúrgicos testigos de Jehová tras asistencia sanitaria ajena al sistema público de salud? / Is the claiming of costs justifiable in Jehovah's witness surgical patients after healthcare that is not part of the public health system?

INTRODUCCIÓN: Los testigos de Jehová rechazan la transfusión sanguínea. El conflicto aparece cuando el enfermo, afiliado a la sanidad pública, acude a centros de cirugía sin sangre, para después reclamar los gastos creados. OBJETIVOS: Análisis de reclamaciones jurídicas de reintegro de gastos en enfermos testigos de Jehová tratados fuera del sistema de salud pública. Comparación de costes, respecto a costes mediante Grupo de Diagnóstico Relacionado (GRD) en un modelo hipotético de asistencia similar e igual estancia en nuestro hospital. MATERIAL Y MÉTODOS: Estudio retrospectivo de sentencias de tribunales Superior de Justicia, Supremo y Constitucional. Análisis económico: utilizamos información clínica obtenida en la sentencia, para procesarlo en GRD, de nuestro hospital con 3MHealth Information Systems. Resultado/conclusiones: El Estado no tiene el deber de financiar aspectos religiosos o ajenos al interés general. El establecimiento de protocolos de actuación evitaría conflictos éticos. Diferencias difícilmente justificables en costes solicitados, 431.001,66 €, y en relación a un modelo con igual estancia, 397.404,48 €

INTRODUCTION: Jehovah's witnesses refuse blood transfusions. The conflict arises when the patient, entitled to public health treatment, come to surgical centres without blood, to later claim the costs incurred. OBJECTIVES: To analyse the legal claims for the refunding of costs by Jehovah's witnesses treated outside the public health system. To make a cost comparison regarding this, using Diagnosis Related Groups (DRGs) in a similar hypothetical healthcare model and equal to a stay in our hospital. MATERIAL AND METHODS: A retrospective study was made of the High, Constitutional, and Supreme Court rulings. A cost analysis was made using the clinical information obtained in the rulings, to process this in the DRG in our hospital using 3MHealth Information Systems. Results/CONCLUSIONS: The State is not obliged to finance religious aspects or those outside the general interest. The establishment of working protocols would avoid ethical conflicts. There are very difficult to justify differences in the costs demanded, 431,001.66 €, and compared to a model with an equal stay, 397,404.48 €

[Is the claiming of costs justifiable in Jehovah's witness surgical patients after healthcare that is not part of the public health system?]. / ¿Es justificable el reintegro del gasto en enfermos quirúrgicos testigos de Jehová tras asistencia sanitaria ajena al sistema público de salud?

INTRODUCTION: Jehovah's witnesses refuse blood transfusions. The conflict arises when the patient, entitled to public health treatment, come to surgical centres without blood, to later claim the costs incurred. OBJECTIVES: To analyse the legal claims for the refunding of costs by Jehovah's witnesses treated outside the public health system. To make a cost comparison regarding this, using Diagnosis Related Groups (DRGs) in a similar hypothetical healthcare model and equal to a stay in our hospital. MATERIAL AND METHODS: A retrospective study was made of the High, Constitutional, and Supreme Court rulings. A cost analysis was made using the clinical information obtained in the rulings, to process this in the DRG in our hospital using 3MHealth Information Systems. RESULTS/CONCLUSIONS: The State is not obliged to finance religious aspects or those outside the general interest. The establishment of working protocols would avoid ethical conflicts. There are very difficult to justify differences in the costs demanded, 431,001.66 €, and compared to a model with an equal stay, 397,404.48 €.

[Hepatic brucelloma: diagnosis and treatment]. / Pautas diagnósticas y actitud terapéutica ante un bruceloma hepático.

Liver involvement due to brucellosis can occur during the acute or the chronic phase of the disease. The marked tendency toward circumscription can give rise to hepatic pseudotumoral lesions with a calcified granulomatous appearance, called brucellomas. Surgery is the only correct treatment, including Brucella PCR in the central calcified lesion, because serological studies are often inconclusive.

Pautas diagnósticas y actitud terapéutica ante un bruceloma hepático / Hepatic brucelloma: diagnosis and treatment

La afectación hepática en el transcurso clínico de una brucelosis puede producirse tanto en la fase aguda como en la fase crónica de la enfermedad. La clara tendencia hacia la circunscripción puede dar lugar a lesiones hepáticas seudotumorales, de aspecto granulomatoso y calcificadas, denominados brucelomas. El tratamiento quirúrgico es la única actitud terapéutica correcta. Se debe incluir la técnica de reacción en cadena de la polimerasa para Brucella en la lesión calcificada central, ya que con frecuencia los estudios serológicos no son concluyentes (AU)

Liver involvement due to brucellosis can occur during the acute or the chronic phase of the disease. The marked tendency toward circumscription can give rise to hepatic pseudotumoral lesions with a calcified granulomatous appearance, called brucellomas. Surgery is the only correct treatment, including Brucella PCR in the central calcified lesion, because serological studies are often inconclusive (AU)

Bazo ectópico o errante asociado a leucopenia y plaquetopenia / No disponible

No disponible

[Surgery and blood transfusion in Jehovah's witnesses: a medical-legal review]. / Cirugía y transfusión urgente en el paciente testigo de Jehová: revisión de las implicaciones médico-legales.

Conflict between two ethical and legal conditions such as life and freedom is frequent in medical practice. Jurisdiction has handed down contradictory decisions and edicts when placing life (and therefore the lex artis of physicians) above Jehovah's witnesses' right to refuse blood transfusions. However, in principle, the right to life takes precedence over the patient's autonomy because, based on professional ethics, physicians have a duty to attempt a cure. Thus the patient's liberty is infringed, giving rise to interventions that may give rise to complaints and lawsuits. The present article provides an overview of each and every situation that could give rise to doubts, as well as an analysis of jurisdiction and the legal responsibilities involved in surgical decisions about Jehovah's witnesses.

Cirugía y transfusión urgente en el paciente testigo de Jehová: revisión de las implicaciones médico-legales / Surgery and blood transfusion in Jehovah’s witnesses: a medical-legal review

Frecuentemente, en nuestra actividad médica, aparece una situación de conflicto entre dos valores jurídicos fundamentales, como son la vida y la libertad. Existen decisiones y autos contradictorios a lo largo de la jurisprudencia a la hora de anteponer por un lado la vida del enfermo (y, por lo tanto, la lex artis del profesional médico) a la libertad del paciente testigo de Jehová para rechazar las transfusiones de hemoderivados. Si bien, en principio, el derecho a la vida se antepone a la autonomía del enfermo porque el facultativo asume, en función de su ética profesional, el deber de intentar la curación. De esta forma se infringe la libertad del paciente, y puede dar lugar a actuaciones que pueden ser susceptibles de reclamaciones y responsabilidades jurídicas. Por ello, realizamos un planteamiento general de todas y cada una de las posibles situaciones capaces de generar dudas, además de un análisis de la jurisprudencia y la posible responsabilidad derivada de nuestras decisiones (AU)

Conflict between two ethical and legal conditions such as life and freedom is frequent in medical practice. Jurisdiction has handed down contradictory decisions and edicts when placing life (and therefore the lex artis of physicians) above Jehovah's witnesses' right to refuse blood transfusions. However, in principle, the right to life takes precedence over the patient's autonomy because, based on professional ethics, physicians have a duty to attempt a cure. Thus the patient's liberty is infringed, giving rise to interventions that may give rise to complaints and lawsuits. The present article provides an overview of each and every situation that could give rise to doubts, as well as an analysis of jurisdiction and the legal responsibilities involved in surgical decisions about Jehovah's witnesses (AU)

[Microcytic and hypochromic anemia due to a high-grade undifferentiated, embryonal, pleomorphic sarcoma]. / Anemia microcítica e hipocroma como consecuencia de un sarcoma pleomorfo indiferenciado de alto grado.

Undifferentiated (embryonal) sarcoma (UES) of the liver is a primary malignant tumor, rarely diagnosed in adults. Because of the absence of specific symptoms, rapid tumor growth, and normality of the common tumor markers, this neoplasm has a poor prognosis. Histologically, UES of the liver is characterized by anaplastic cells within myxoid matrix. Histological, immunohistochemical and chromosomic alterations are similar in UES and in mesenchymal hamartoma, suggesting a relation between these entities. The mainstay of treatment is surgery, while adjuvant treatment could increase survival.

Anemia microcítica e hipocroma como consecuencia de un sarcoma pleomorfo indiferenciado de alto grado / Microcytic and hypochromic anemia due to a high-grade undifferentiated, embryonal, pleomorphic sarcoma

El sarcoma indiferenciado (embrionario) del hígado es una neoplasia primaria maligna, que se diagnostica de forma excepcional en el adulto. La ausencia de síntomas específicos, el rápido crecimiento tumoral y la normalidad de los marcadores tumorales hacen de esta neoplasia un proceso de mal pronóstico. Histológicamente, se caracteriza por la presencia de una matriz mesenquimal y un pleomorfismo nuclear. Diversas características histológicas y cromosómicas harían pensar en una posible relación con el hamartoma mesenquimal. El tratamiento de elección es la cirugía, y puede recurrirse a la quimioterapia como tratamiento coadyuvante

Undifferentiated (embryonal) sarcoma (UES) of the liver is a primary malignant tumor, rarely diagnosed in adults. Because of the absence of specific symptoms, rapid tumor growth, and normality of the common tumor markers, this neoplasm has a poor prognosis. Histologically, UES of the liver is characterized by anaplastic cells within myxoid matrix. Histological, immunohistochemical and chromosomic alterations are similar in UES and in mesenchymal hamartoma, suggesting a relation between these entities. The mainstay of treatment is surgery, while adjuvant treatment could increase survival

Utilidad de la determinación sérica de factor de crecimiento del endotelio vascular en el postoperatorio del cáncer colorrectal / Postoperative serum vascular endothelial growth factor can be a marker for colorectal cancer recurrence

No disponible

[Serum vascular endothelial growth factor levels in patients with colorectal cancer and its prognostic significance]. / Valores séricos de factor de crecimiento del endotelio vascular en pacientes con cáncer colorrectal y su significación pronóstica.

BACKGROUND AND OBJECTIVE: Thirty per cent of patients with histologically node-negative colorectal cancer die from disseminated disease. Actually disease stage is the most useful prognostic parameter although it is not sufficient. Vascular endothelial growth factor (VEGF) is an angiogenic cytokine involved in the progression of tumors. In our study we tried to know the prognostic significance of pre and postoperative serum VEGF levels in patients with colorectal cancer. PATIENTS AND METHOD: Cohort study that included 52 patients with colorectal cancer surgically treated in our Department from 1998 to 2000. Serum VEGF and CEA levels were determined the day before surgery and 30 days after it. RESULTS: Preoperative serum VEGF levels (428.5 [38.5] pg/ml) were higher than in control patients (p=0.008). Serum VEGF levels fallen significantly after surgery (343 [31.2] pg/ml; p=0.001). Pre and postoperative serum VEGF levels in poorly differentiated neoplasms were higher than in well differentiated ones (p=0.009 and p=0.008 respectively). Pre and postoperative serum CEA and VEGF levels were significantly associated with cancer relapse (p=0.037, p=0.017, p=0.048 and p=0.001, respectively). In multivariate analysis only postoperative serum VEGF levels were associated with colorectal cancer relapse (p=0.003; HR=1.007; 95% CI, 1.002-1.012). Pre and postoperative CEA levels (p<0.001 and p=0.001 respectively) and postoperative VEGF levels (p=0.001), were associated with mortality. In multivariate analysis only tumor stage (p=0.01) and postoperative serum VEGF levels (p=0.02) were associated with mortality. Postoperative serum VEGF determination and pre and postoperative CEA levels raise specificity and positive predictive values to 100% in relation to mortality. CONCLUSIONS: Pre and postoperative serum VEGF determination has prognostic significance, regardless of tumor stage, in patients with colorectal cancer. In survival methods, postoperative VEGF levels >343 pg/ml are significantly with tumor relapse and mortality. These results suggest the use of serum VEGF levels as a prognostic and monitoring factor besides CEA.

Valores séricos de factor de crecimiento del endotelio vascular en pacientes con cáncer colorrectal y su significación pronóstica / Serum vascular endothelial growth factor levels in patients with colorectal cancer and its prognostic significance

FUNDAMENTO Y OBJETIVO: Un tercio de los enfermos con cáncer colorrectal intervenidos quirúrgicamente con intención curativa fallece a consecuencia de una recidiva de la enfermedad. La estadificación anatomopatológica constituye el indicador pronóstico más fiable, aunque resulta insuficiente. Intentamos conocer el valor pronóstico de la determinación sérica pre y postoperatoria del factor de crecimiento del endotelio vascular (VEGF) en enfermos con cáncer colorrectal. PACIENTES Y MÉTODO: Se realizó un estudio de cohorte de 52 enfermos con cáncer colorrectal intervenidos quirúrgicamente en nuestro Servicio (Complejo Hospitalario de Ciudad Real) con carácter electivo entre 1998 y 2000. Se determinaron las concentraciones séricas de VEGF y antígeno carcinoembrionario (CEA), el día previo a la intervención quirúrgica y 30 días después. RESULTADOS: Los valores preoperatorios de VEGF en enfermos con cáncer colorrectal (media de 430,8 [38,5] pg/ml) son más elevados que en los controles (p = 0,008). A los 30 días de la intervención quirúrgica hubo un descenso significativo de los valores de VEGF (343 [31,2] pg/ml; p < 0,0001). Las neoplasias con mala diferenciación presentaron valores pre y postoperatorios más elevados (p = 0,009 y p = 0,008, respectivamente) que aquellas con buena diferenciación. Los valores pre y postoperatorios de VEGF y CEA se relacionaron significativamente con la recidiva de la enfermedad (p = 0,037, p = 0,017, p = 0,048 y p = 0,001, respectivamente). En el estudio multivariante sólo los valores postoperatorios de VEGF se relacionaron con recidiva de la enfermedad (p = 0,003; razón de riesgo = 1,007; intervalo de confianza del 95 por ciento, 1,002-1,012). Los valores pre y postoperatorios de CEA (p < 0,001 y p = 0,001, respectivamente) y postoperatorios de VEGF (p = 0,001) se relacionaron con una menor supervivencia de los enfermos. En el análisis multivariante, sólo la estadificación anatomopatológica (p = 0,01) y los valores de VEGF (p = 0,02) se relacionaron con la mortalidad. La determinación sérica de VEGF en el postoperatorio, junto a las determinaciones pre y postoperatoria de CEA, incrementó la especificidad y el poder predictivo positivo al 100 por ciento respecto a la mortalidad del enfermo. CONCLUSIONES: La determinación sérica pre y postoperatoria de VEGF puede considerarse un marcador pronóstico relevante, independiente de la estadificación neoplásica en el cáncer colorrectal. Valores postoperatorios superiores a 343 pg/ml, en modelos uni y multivariantes, se relacionan significativamente con la recidiva y mortalidad del enfermo, por lo que deberíamos valorar su utilización como marcador de seguimiento junto al CEA, habitualmente utilizado (AU)

Infección nosocomial por stenotrophomonas maltophilia en enfermos intervenidos quirúrgicamente / Nosocomial infection due to Stenotrophomona maltophilia in surgically treated patients

No disponible