Predicting kidney outcomes among Latin American patients with lupus nephritis: The prognostic value of interstitial fibrosis and tubular atrophy and tubulointerstitial inflammation.

OBJECTIVE: To assess the effect of tubulointerstitial inflammation (TII) and interstitial fibrosis and tubular atrophy (IFTA) on kidney survival in lupus nephritis (LN). METHODS: Two hundred eighty five patients with biopsy-proven LN were retrospectively studied. Kidney survival was defined as the time from initial biopsy to end-stage kidney disease (ESKD), dialysis, or transplant. Kidney survival analysis was performed by the Kaplan-Meier method and the statistical difference between survival curves compared by the log-rank test. Cumulative incidence functions with competing risk of death for kidney survival were also graphed. Multivariable Cox proportional hazards regression and competing-risk analyses were performed to identify independent predictors of ESKD. RESULTS: Fifty-seven patients (20%) progressed to ESKD during a median time of 4.2 (2.0-55.2) months after biopsy. TII was present in 206 (72.3%) biopsies, while IFTA in 99 (34.7%) biopsies. Patients with moderate-to-severe IFTA had worse kidney survival than those with none or mild IFTA in both the Kaplan-Meier (p = 0.018) and the competing-risk analyses (p = 0.017). Patients with class IV ± V LN had worse kidney survival than those with non-class IV LN by the Kaplan-Meier method (p = 0.050), but not in the competing-risk analysis (p = 0.154). Worse kidney survival was also found among those with fibrous crescents than those without, in both the Kaplan-Meier (p = 0.010) and the competing-risk (p = 0.011) analyses. By multivariable Cox regression analysis, older age (HR 1.04, 95% CI 1.01-1.07) and class IV ± V LN (HR 5.06, 95% CI 1.82-14.09) were associated with higher risk of ESKD after adjusting for sex, ethnicity, TII, and IFTA. By competing-risk analyses, class IV ± V LN (SHR 3.32, 95% CI 1.25-8.83) and no response to immunosuppressive therapy (SHR 4.55, 95% CI 1.54-13.41) were associated with a higher risk of ESKD, while eGFR >90 mL/min/1.73 m2 (SHR 0.98 for each ml/min/1.73 m2, 95% 0.97-0.99) with a lower risk. CONCLUSIONS: Patients with moderate-to-severe IFTA had worse kidney survival than those with none or mild IFTA. Worse kidney survival was also found among those with class IV LN and fibrous crescents versus those without IV LN and fibrous crescents, respectively.

[Analysis of budgetary impact of COVID-19 vaccination in Latin AmericaAnálise do impacto orçamentário da vacinação contra a COVID-19 na América Latina]. / Análisis de impacto presupuestal de la vacunación contra COVID-19 en América Latina.

Objective: To estimate the budgetary impact of COVID-19 vaccination in six Latin American countries: Argentina, Brazil, Chile, Colombia, Mexico, and Peru, during the 2021-2022 biennium. Methods: Vaccines from Sinopharm (BBIBP-CorV), Janssen (JNJ-78436735), Gamaleya Institute (Gam-COVID-Vac), Sinovac (CoronaVac), CanSino (Convidecia), AstraZeneca (Vaxzevria), Moderna (mRNA-1273), and Pfizer (BNT162b2) were evaluated, according to their availability in each country. The health system perspective was adopted, so that only direct health care costs were included. The time horizon adopted took into account the implementation times of each vaccination plan, excluding children under 16 years of age and pregnant persons. The following costs were included: cost of vaccination/vaccine administration and costs of hospitalization (general isolation, stepdown care, and intensive care). Two vaccination scenarios were compared: 1) population wanting to be vaccinated (according to national surveys); and 2) population that should be vaccinated (total population susceptible to vaccination). The aggregate costs for each vaccination scenario were compared with the no-vaccination scenario. Deterministic and probabilistic sensitivity analyses were also performed. Results: The different COVID-19 vaccination regimens available in Latin America generate potential savings ranging from USD 100 million to USD 1.5 billion per country for the 2021-2022 biennium, assuming that the vaccination plan proposed for each country is fully implemented. Conclusions: COVID-19 vaccination is a strategy that not only reduces morbidity and mortality in Latin America, but also generates potential savings for health systems in the region.

Objetivo: Estimar o impacto orçamentário da vacinação contra a COVID-19 em seis países da América Latina: Argentina, Brasil, Chile, Colômbia, México e Peru, no período 2021-2022. Métodos: Foram avaliadas as vacinas da Sinopharm (BBIBP-CorV), Janssen (JNJ-78436735), Instituto Gamaleya (Gam-COVID-Vac), Sinovac (CoronaVac), CanSino (Convidecia), AstraZeneca (Vaxzevria), Moderna (mRNA-1273) e Pfizer (BNT162b2), conforme a disponibilidade para cada país. Adotou-se a perspectiva do sistema de saúde, de forma que só foram incluídos custos médicos diretos. O horizonte temporal foi adotado levando em consideração os tempos de implementação de cada plano de vacinação, excluindo crianças menores de 16 anos e gestantes. Foram incluídos os seguintes custos: custos de vacinação e aplicação, custos gerais de hospitalização, isolamento, e cuidados intermediários e intensivos. Compararam-se dois cenários de vacinação: 1) população disposta a se vacinar (com base em pesquisas nacionais) e 2) população que deveria ser vacinada (total elegível de vacinação). Os custos agregados para cada cenário de vacinação foram comparados com o cenário de não vacinação. Além disso, foram realizadas análises de sensibilidade determinísticas e probabilísticas. Resultados: Os diferentes esquemas de vacinação contra a COVID-19 disponíveis na América Latina geram economias potenciais entre 100 milhões e 1,5 bilhão de dólares por país para o período 2021-2022, considerando a implementação completa do plano de vacinação previsto em cada país. Conclusões: A vacinação contra a COVID-19 é uma estratégia que, além de reduzir a morbidade e a mortalidade na América Latina, gera economias potenciais para os sistemas de saúde da região.

Photovaporization of the prostate with GreenLight™ laser 180 W XPS versus transurethral resection of the prostate with monopolar energy for the treatment of benign prostatic enlargement: a cost-utility analysis from a healthcare perspective.

PURPOSE: To assess the cost-utility of the photovaporization of the prostate (PVP) with GreenLight™ laser 180 W XPS compared to transurethral resection of the prostate with monopolar energy (M-TURP) for lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) from a healthcare perspective in Colombia. METHODS: We designed a Markov model to compare four health states following treatment with either PVP or M-TURP to estimate expected costs and outcomes. We used the results of the only randomized clinical trial published to date comparing PVP versus M-TURP to estimate surgical outcomes, complications, re-operation and re-intervention rates. Time horizon was defined at 2 years with four cycles of 6 months each. Resource-use estimation involved a random selection of clinical records from a local institution and cost list from public healthcare system. Costs were obtained in Colombian pesos and converted to US dollars. Threshold was defined at three-times the Colombian gross domestic product (GDP) per capita. Quality-adjusted-life-years (QALYs) were used based on the utilities of the available literature. Uncertainty was analyzed with deterministic and probabilistic models using a Monte Carlo simulation. RESULTS: Patients who underwent PVP gained 1.81 QALYs compared to 1.59 with M-TURP. Costs were US$6797.98 and US$7777.59 for M-TURP and PVP, respectively. Incremental cost-effectiveness ratio was US$4452.81 per QALY, favoring PVP as a cost-effective alternative in our context. CONCLUSIONS: In Colombia, with current prices, PVP is cost-effective when compared to M-TURP for LUTS due to BPE for a 2-year time horizon.

Psychotherapists' experiences of telepsychotherapy during the COVID-19 pandemic in Argentina: impact on therapy setting, therapeutic relationship and burden.

In order to prevent the spread of the coronavirus in Argentina, quarantine and distancing measures were adopted. This has led to a large increase in the use of online psychotherapy. Several international studies have already examined the transition from face-to-face therapy to telepsychotherapy during the COVID-19 pandemic from a therapist perspective, but within these studies, the Latin American context is not represented. To fill this research gap, this qualitative study explored the Argentinean psychotherapists' experiences with online psychotherapy during the COVID-19 pandemic by means of in-depth interviews and content analysis. Based on the international literature, an interview guideline was created which covered three main topics: setting, therapeutic relationship, and burden among therapists. For the analysis of the therapists' answers, a detailed codebook was developed. Effects were identified in all three areas investigated. The nine interviewed psychotherapists described unfavorable therapy conditions which affected the therapeutic setting, the psychotherapeutic methods and contents. Positive effects in the therapeutic relationship included patients being more open, but also negative effects such as discontinuation of therapies were reported. Therapists experienced telepsychotherapy as more exhausting than in-person psychotherapy, but they considered it a valuable tool during the pandemic, and the transition an enriching experience. These results, which are partially consistent with international findings, have practical implications for the practice of telepsychotherapy in Argentina. Technical conditions should be improved and patients' privacy during the session should be ensured. Treatment techniques and diagnostics need to be adapted for their use in telepsychotherapy.

Strategies to improve cost effectiveness of robotic assisted laparoscopic radical prostatectomy in emerging economies.

To assess the cost-effectiveness of the robotic-assisted laparoscopic radical prostatectomy (RALRP) compared to open radical prostatectomy (ORP) for localized prostate cancer from a healthcare perspective in Colombia. A systematic review was conducted in Embase, Scopus, Web of Science, PubMed, and Cochrane CENTRAL databases, to identify relevant publications up to January 2020 to summarize clinical outcomes related to effectiveness of robot-assisted and open radical prostatectomy. A tree decision model was designed given the clinical outcomes and possibilities of complication and success. Outcomes were defined as complications according to Clavien - Dindo classification and success measured as urethral stricture rate. Cost was divided into two categories: surgical procedure and complications. Incremental cost-effectiveness ratio (ICER) was calculated and a deterministic sensitivity analysis was performed to evaluate the impact of the uncertainty on the conclusions of the model. A 90-day horizon was defined. Direct medical costs associated with RALRP were $6.511 ($ 5.127- $8.138), and for ORP were $4.476 ($2.170-$ 6.511). The average cost for complication management was rated at $ 327 for RALRP and $ 382 for ORP, based on an augmented risk of post-operative urethral stricture in the ORP group (2.4% vs 10.8%). ICER was calculated in USD $18.987. The cost of RALRP has to be reduced to around USD 5.345 to achieve an ICER under 1 GDP making the intervention feasible. Using a 3 GDP per capita threshold, the implementation of RALRP could be cost-effective for the treatment of localized prostate cancer in emerging economies. Bolder measures including the use of one needle carrier, three robotic arms, and a shorten hospitalization program of 24 h, can save around $1000 for each patient, achieving the goal cost of $5345 needed for a favorable ICER.

Impact of hydrocolloid dressings in the prevention of pressure ulcers in high-risk patients: a randomized controlled trial (PENFUP).

It is uncertain whether hydrocolloid dressings, a more costly intervention than offering standard care with petrolatum, is superior to prevent pressure ulcers among hospitalized high-risk adults. Randomized, parallel-group, open-label, superiority trial with an active control group, blinded for investigators, event validators, and analysts (December 1, 2015 to December 12, 2017). Eligible patients were ≥ 18 years of age with intact skin judged as high-risk for skin ulcers (Braden scale), admitted to surgical or medical wards of two tertiary-level hospitals. Participants were randomized (1:1) to protection with hydrocolloid dressings or petrolatum. The primary outcome was the first occurrence of pressure ulcers (with post-injury photographs adjudicated by three judges) under intention-to-treat analysis. Based on prior cost analysis, and the available resources (assumed incidence of 6 ulcers/1000 patient-days in controls), inclusion of up to 1500 participants allowed to surpass a one-sided superiority threshold > 5% based on a target efficacy > 40% for dressings. We planned an economic analysis using a decision tree model based on the effectiveness of the study results from a perspective of the third payer of health care. After inclusion of 689 patients (69 events), the trial was stopped for futility after a planned interim analysis (conditional power < 0.1 for all scenarios if the trial was completed). Pressure ulcers had occurred in 34 (10.2%) patients in the intervention group [9.6 per 1000 patient-days] and 35 (9.9%) participants in the control group [7.9 per 1000 patient-days], HR = 1.07 [95% CI 0.67 to 1.71]. The estimated incremental cost for dressings (a dominated strategy) was USD 52.11 per patient. Using hydrocolloid dressings was found similar to petrolatum for preventing pressure ulcers among hospitalized high-risk patients. As it conveys additional costs, and in this study was unlikely to demonstrate enough superiority, this strategy did not overcome conventional skin care.Trial registration: ClinicalTrials.gov identifier (NCT number): NCT02565745 registered on December 1, 2015.

Costos Unitarios Para Procedimientos en Salud en Colombia: Un Insumo Decisivo Para las Evaluaciones Económicas en Salud.

OBJECTIVES: Since 2011, there is a recommendation in Colombia to value health procedures: apply the tariffs of a 2001 manual used in a former public insurer with an adjustment factor of 35% (Instituto de Seguros Sociales [ISS] 2001). Nevertheless, the adjustment factor is not periodically updated, which limits the external validity of studies using these values and might also affect internal validity of studies, given that we are using possibly biased unit costs. This study aimed to compare unit values for health procedures using 2 sources: the ISS 2001 manual and individual records of service provision in Colombia (Registros Individuales de Prestación de Servicios de Salud [RIPS]), to evaluate the validity of the adjustment factor proposed in the Colombian reference case. METHODS: Unit values of health procedures reported in the Los Registros Individuales de Prestación de Servicios de Salud between 2013 and 2016 were compared with the value resulting from applying the assumption of ISS 2001 +35%. Rate variations were analyzed at the national level, by region and type of procedure. RESULTS: In the base case, the average rate variation at the national level was 142% with respect to the base value of the ISS manual; the value for nonsurgical procedures is 63% higher than the ISS 2001 rates, whereas for surgical procedures the difference is 299%. CONCLUSIONS: It is necessary to update the current recommendation in Colombia to estimate the unit cost of health procedures, to improve the external validity of economic evaluations and budget impact analysis in the country.

Cost-effectiveness of a Dengue Vector Control Intervention in Colombia.

Dengue is a public health problem in Colombia and in the municipality of Girardot, an area of high risk for dengue transmission. We present the results of an economic evaluation from the societal perspective and 1-year time horizon comparing the regular control program for dengue prevention versus an intervention that comprised an environmental management strategy by covering the most Aedes aegypti productive breeding sites with insecticide covers, community actions, and educational activities. The effectiveness of the intervention was measured as the reduction in probability of dengue infection obtained from a community trial. Resource use was estimated from clinical records that were validated by clinical experts; unit costs were taken from national tariffs. Patient costs were obtained from a household survey. We found that the intervention generated an additional cost of USD20.9 per household and an incremental effectiveness of 0.00173 (reduction in the probability of reported dengue cases). Overall, both alternatives generate similar effectiveness, but the new intervention was associated with increasing costs. We conclude the new intervention is a potentially cost-effective option in areas where high prevalence of dengue exists.

Propuesta psicoterapéutica para Juliet en la serie New Amsterdam. Limitaciones de seductoras esperanzas / Psychotherapeutic Proposal for Juliet in the Series New Amsterdam

Este trabajo, se focaliza en la dilemática propuesta psicoterapéutica de una niña de 11 años, desarrollada a posteriori de arribar a un diagnóstico "insensibilidad afectiva", también referida como severas perturbaciones en los procesos de empatía. El análisis e interrogantes planteados del proceso diagnóstico y psicoterapéutico se realiza con el sustrato de un enfoque psicoanalítico relacional que sostiene que en sentido estricto no existe mente aislada, tanto desarrollo como trauma devienen en la dimensión relacional intersubjetiva contextual e históricamente situada. El devenir humano se configura en las complejas correlaciones entre múltiples combinaciones ­conscientes e inconscientes­ de las propiedades genéticas, congénitas y experiencias vividas, en el marco de los abanicos de influjos identificatorios, emplazados en matrices relacionales, que operan como sustrato de las configuraciones de la empatía. La propuesta psicoterapéutica centrada solo en una parte de la conducta manifiesta de Juliet y en su necesidad manifiesta de halagos que ­cuando son puestas en riesgo sobreviene un derrumbe que propicia los acting out de violencia extrema­, deja por fuera: ­los recorridos de configuración de la problemática y sus significados, intra e intersubjetivo; ­pactos conscientes e inconscientes intra e intergeneracionales; ­función de las defensas y conductas manifiestas en el equilibrio intra e intersubjetivo; ­riesgo a convocar miedos inconscientes ante la invitación a conmoverse ante el sufrimiento del semejante. Asimismo, cabe subrayar, que se deja fuera de escena al niño violentado y se lo pone en riesgo a ser revictimizado, todo un fallido ético

This work focuses on the dilemmatic psychotherapeutic proposal of an 11­year-old girl, developed after arriving at a diagnosis "affective insensitivity", also referred to as severe disturbances in the empathy processes. The analysis and questions raised about the diagnostic and psychotherapeutic process is carried out with the substrate of a relational psychoanalytic approach that maintains that in a strict sense there is no isolated mind, both development and trauma become the contextual and historically situated intersubjective relational dimension. Human becoming is configured in the complex correlations between multiple combinations ­conscious and unconscious­ of genetic and congenital properties and lived experiences, within the framework of the fans of identifying influences, located in relational matrices, which operate as a substrate of the configurations of empathy. The psychotherapeutic proposal focused only on a part of Juliet's manifest behavior and on her manifest need for flattery that ­when they are put at risk, a collapse occurs that favors the acting out of extreme violence­, leaves out: ­the configuration paths of the problem and its meanings, intra and intersubjective; ­conscientious and unconscious intra and intergenerational pacts; ­function of defenses and manifest behaviors in intra and intersubjective balance; ­risk of invoking unconscious fears at the invitation to be moved by the suffering of others. Likewise, it should be noted that the abused child is left out of the picture and is put at risk of being re-victimized, a ethical failure

Dinámica funcional de la comunidad bacteriana del lodo activado de una planta de tratamiento de agua residual y su relación con variables ambientales y de operación / Funcional dynamics of the bacterial community from activated sludge wastewater treatment plant and its relationship with environmental and operational variables

RESUMEN El proceso de lodos activados es comúnmente utilizado en plantas de tratamiento de aguas residuales (PTAR) para reducir la concentración de materia orgánica disuelta que llega en el afluente. A pesar de los avances en el estudio de las comunidades microbianas de los lodos activados, falta mucho para entender su potencial funcional y su variabilidad ante las fluctuaciones temporales del afluente y los cambios en la operación de las PTAR. En consecuencia, en este trabajo se analizó la variación del potencial metabólico de la comunidad bacteriana del lodo activado a lo largo de un ciclo anual y se relacionó esa dinámica con variables ambientales y operacionales de una PTAR con alcantarillado combinado. La predicción del metagenoma de la comunidad bacteriana se realizó con PICRUSt2. Esta aproximación permitió evidenciar el fenómeno de redundancia funcional en la comunidad. También, se logró analizar la fluctuación temporal de los genes asociados a procesos relacionados con los ciclos del nitrógeno y azufre y su relación con variables ambientales y operacionales de la PTAR. Se encontró que dichos procesos están relacionados diferencialmente con la precipitación y los cambios en la edad de lodo observados para el periodo estudiado. Estos resultados contribuyen al entendimiento de las dinámicas de la comunidad bacteriana con relación al funcionamiento de este tipo de sistemas biotecnológicos.

ABSTRACT Activated sludge process is commonly used in wastewater treatment plants (WWTP) where a microbial community removes the organic matter from the influent. Despite the advances in the study of this community, there is still a gap of knowledge about its functional potential and its variability due to temporary fluctuations of the influent and the WWTP operation. Therefore, this work analyzed the metabolic potential variation of the activated sludge bacterial community throughout an annual cycle. Furthermore, the dynamics of the bacterial community was related to environmental and operating variables of a WWTP with combined sewerage. The metagenome prediction of the bacterial community was carried out with PICRUSt2. This approach allowed to demonstrate the phenomenon of functional redundancy in the community. Moreover, the temporal fluctuation of genes associated with the nitrogen and sulfur cycles and their relationship with environmental and the operating variables of the WWTP were analyzed. It was found that those processes were differentially related to precipitation events and variations in the sludge age observed during the studied period. These results contribute to the understanding of the bacterial community dynamics in relation to the functioning of this type of biotechnological systems.

Duelos en la niñez y psicoterapia en tiempos de pandemia / Childhood grief and psychotherapy in pandemic times

El propósito es relacionar descriptores epocales disruptivos de la pandemia, en términos de procesos de sumatoria de duelos, con vicisitudes del trabajo diagnóstico y psicoterapéutico con niños/as, en ámbitos públicos y privados del 2020. El psiquismo es una organización abierta, de dinámicas reorganizaciones de múltiples combinaciones conscientes e inconscientes de experiencias vividas. Los procesos de duelo y sus destinos son intra e intersubjetivos, implican intersecciones de mundos subjetivos en interacción. En la niñez las dimensiones intrapsíquicas se enlazan con la comprensión de la muerte y separaciones prolongadas, tramas familiares y redes sociales. El reporte de los primeros resultados descriptivos de una investigación cualitativa, refieren dificultades y fortalezas de los pasajes de la psicoterapia presencial a la mediada por tecnologías sincrónicas. La comprensión de expresiones sintomáticas y elaboraciones u obstrucciones del duelo, pretende constituir aportes para proceso diagnósticos y psicoterapéuticos que propicien reconstrucciones intra e intersubjetivas requeridas por nuevas normalidades en curso(AU)

The purpose is to relate disruptive epochal descriptors of the pandemic, in terms of processes of grief summation, with vicissitudes of diagnostic and psychotherapeutic work with children, in public and private settings in 2020. The psyche is an open organization, of dynamic reorganizations of multiple conscious and unconscious combinations of lived experiences. Mourning processes and their destinies are intra and intersubjective, involving intersections of interacting subjective worlds. In childhood, the intrapsychic dimensions are linked to the understanding of death and prolonged separations, family networks and social networks. The report of the first descriptive results of a qualitative research, refer to difficulties and strengths of the passages from face-to-face psychotherapy to that mediated by synchronous technologies. The understanding of symptomatic expressions and elaborations or obstructions of grief, intends to constitute contributions for diagnostic and psychotherapeutic processes that propitiate intra and inter-subjective reconstructions required by new normalities in progress(AU)

Evaluación costo-efectividad de las prótesis con superficie cerámica-polietileno vs. metal-polietileno para reemplazo articular primario de cadera en Colombia / Cost-Effectiveness of Ceramic-Polyethylene Vs Metal-Polyethylene Bearing for Primary Total Hip Replacement in Colombia

Introducción Existe una diferencia estadísticamente significativa del 1.2% en la tasa de revisión a 15 años a favor de cerámica- polietileno altamente entrecruzado (CP), demostrada en el registro nacional de artroplastia australiano. Nuestro objetivo es evaluar la costo-efectividad entre los pares: cerámica-polietileno altamente entrecruzado (CP) y metal- polietileno altamente entrecruzado (MP) para el pagador en Colombia. Materiales y métodos Se construyó un árbol de decisiones TreeAge Pro® comparando CP vs MP desde la perspectiva del Sistema de Salud Colombiano (SSC). Los parámetros se tomaron de la mejor evidencia disponible, para la efectividad se realizó una revisión sistemática de la literatura y para los costos se usaron tarifas del mercado local. Se determinó la relación de costo-efectividad incremental, asumiendo un horizonte temporal de 15 años y aplicando una tasa de descuento del 5% para costos y efectividad. La incertidumbre fue controlada por un análisis de sensibilidad determinístico y probabilístico. Resultados Para el SSC, con un umbral de 1 PIB per cápita por año de vida ganado ajustado por calidad (AVAC), en adultos llevados a RTC el uso de CP no es costo-efectiva, dado que la efectividad es similar (MP:11,32 AVAC vs CP: 11,36 AVAC) y el costo es tres veces mayor (MP $ 861.826 COP vs CP $ 2.298.090 COP). El análisis de sensibilidad determinístico demuestra que la variable más importante en el resultado es el costo de la cerámica. Discusión Para el SSC el uso rutinario de cabezas de cerámica en RTC no es una estrategia costo-efectiva.

Background There is a statistically significant difference of 1.2% in the revision rate in a 15 year follow in favour of the use of ceramic on highly cross-linked polyethylene (CP) recently described in the Australian National Joint Registry. The purpose of this study is to compare the cost-effectiveness of CP implants and metal-on-highly cross-linked polyethylene (MP) implants in patients undergoing total hip replacement (THR). Materials and methods A TreeAge Pro® decision tree was constructed in order to determine cost-effectiveness between two bearing surfaces: CP or MP from the perspective of the Colombian Health Care System (CHCS). The model parameters where taken from the best available evidence. For the effectiveness, a systematic review of the literature was performed, and costs were taken from local market rates. The incremental cost-effectiveness ratio was determined assuming a time horizon of 15 years, and a discount rate of 5% was used for costs and effectiveness. Cost-effectiveness uncertainty was controlled with deterministic and probabilistic sensitivity analysis. Results For the CHCS, with a 1PIB per capita threshold adjusted per QALY in adults undergoing (THR), the use of a CP implant is not cost-effective, given that the effectiveness is similar (11.32 QALY for MP vs 11.36 QALY for CP), and the cost is three times higher (MP $ 861.826 COP vs CP $ 2.298.090 COP). The deterministic sensitivity analysis showed that the most important variable in the results is the ceramic cost. Discussion for the CHCS the routine use of ceramic-highly cross-linked polyethylene bearing surface in a THR is not a cost-effective strategy.

[The cost-effectiveness of interferon beta treatment in patients with a clinically isolated syndrome in Colombia]. / Costo-efectividad del tratamiento con interferón beta en pacientes con síndrome clínico aislado de alto riesgo en Colombia.

INTRODUCTION: Approximately 85% of patients with multiple sclerosis have an initial demyelinating event. Treatment with interferon beta delays the progression of multiple sclerosis for nearly two years in patients with a clinically isolated syndrome. In Colombia, interferon is very expensive when compared to other countries. OBJECTIVE: We sought to determine the cost-effectiveness of a two-year interferon beta treatment within Colombia in patients with a clinically isolated syndrome. MATERIALS AND METHODS: Based on patient and society perspectives, a cost-effectiveness analysis was conducted using a decision tree. A variety of probabilities were defined after a systematic review of the available literature. The disease costs were calculated by reviewing medical charts at the Hospital San Ignacio University and surveys completed by multiple sclerosis patients. To control for uncertainty in these data, analysis of approximately one-thousand patients was performed using Monte Carlo methods. RESULTS: The two-year treatment cost per patient exceeds Col$ 95,000,000 (US$ 50,000). Approximately 80 % of this cost corresponds to medications (US$ 40,500). The price of relapse and indirect costs totals Col$ 41,632,149 (US$ 21,744) and Col$ 11,656,389 (US$ 6,088), respectively. Treatment represents an increase of 0.06 quality-adjusted life years (QALY). The incremental cost-effectiveness ratio exceeds the threshold, regardless of the use of Monte Carlo methods for analysis. CONCLUSION: Administering interferon beta over the course of two years to high-risk patients with a clinically isolated syndrome is not cost-effective within Colombia.

Abuso sexual infantil y su retorno en la adultez: reflexiones desde un caso clínico / Abús sexual infantil i el retorn a l’adultesa: reflexions des d’un cas clínic / Childhood sexual abuse and its return in adulthood: reflections from a clinical case

La clínica con adultosabusados sexualmente en la infancia es una línea de investigación muy abordada en estudios sobre el abusosexual infantil. El presente trabajo es un estudio descriptivo de caso único con el objetivo de analizar el materialclínico de una paciente de veinticinco años que sufrió abuso intrafamiliar en la infancia. Este material se extraede entrevistas de un proceso psicoterapéutico. En primer lugar, se realiza la descripción del caso clínico y lue-go se articula con análisis teórico psicoanalítico. Se profundiza en: desubjetivación, traumatismo, mecanismosdefensivos y desamparo, acomodación, síntomas, elaboración terapéutica y contexto patriarcal. Por último, sereflexiona sobre el ideal de familia como dadora incondicional de cuidado y se plantea al abuso sexual infantilcomo síntoma social, siendo una compleja problemática que requiere de abordajes interdisciplinarios.(AU)

The clinic with sexually abu-sed adults in childhood is a line of research that has been widely addressed in studies on child sexual abuse. Thepresent work is a descriptive single case study with the aim of analyzing the clinical material of a twenty-five yearold patient who suffered intrafamilial abuse in childhood. This material is extracted from interviews of a psychothe-rapeutic process. First, a description of the clinical case is made and then it is articulated with psychoanalytictheoretical analysis. It is deepened in: desubjectivation, traumatism, defensive mechanisms and helplessness, ac-commodation, symptoms, therapeutic elaboration and patriarchal context. Finally, we reflect on the ideal of thefamily as an unconditional giver of care and consider child sexual abuse as a social symptom, a complex problemthat requires interdisciplinary approaches.(AU)

La clínica amb adults abusats sexual-ment a la infància és una línia de recerca molt abordada en estudis sobre l'abús sexual infantil. Aquest treball ésun estudi descriptiu de cas únic amb l'objectiu d'analitzar el material clínic d'una pacient de vint-i-cinc anys queva patir abús intrafamiliar a la infància. Aquest material s’extreu d’entrevistes d’un procés psicoterapèutic. Enprimer lloc, es fa la descripció del cas clínic i després s’articula amb anàlisi teòrica psicoanalítica. S'aprofundeixen: desubjectivació, traumatisme, mecanismes defensius i desemparament, acomodació, símptomes, elaboracióterapèutica i context patriarcal. Finalment, es reflexiona sobre l’ideal de família com a donadora incondicionalde cura i es planteja l’abús sexual infantil com a símptoma social, cosa que és una problemàtica complexa querequereix abordatges interdisciplinaris.(AU)

Tramas de la constitución subjetiva y la complejidad del diagnóstico de niños desde un enfoque relacional (parte 2) / Networks of subjetive constitution and the complexity of the diagnosis of children from a relational perspective (2nd part)

Este trabajo amplia uno precedente. Aporta al abordaje del diagnóstico y sus enlaces con las vicisitudes de la recomendación terapéutica; en términos de diferenciar entre dificultades por déficits, conflictos o reconstrucciones subjetivas en curso. Para trazar ejes conceptuales que delinean estas diferencias, como figura didáctica, puntualizamos observables evolutivos, organizados en torno a las primeras ligazones amorosas, un segundo tiempo de diferenciaciones amorosas y un tercero de descubrimiento de la alteridad del otro. Observables que se constituyen las capas profundas de la mente, coexisten y transforman a lo largo de la vida. En pos de señalar la importancia de elaborar diagnósticos que den cuenta de lo constituido y sus transformaciones, de déficits y/o dificultades nos focalizamos en la niñez. Dos supuestos básicos guían esta presentación; en la vida de una persona el diagnóstico nunca resulta neutro, es terapéutico o iatrogénico, tanto desarrollo como trauma devienen en la dimensión relacional intersubjetiva

This work expands one precedent. It contributes to the approach of the diagnosis and its links with the vicissitudes of the therapeutic recommendation; In terms of differentiating between difficulties due to ongoing deficits, conflicts or subjective reconstructions. As a didactic device, we decided to consider developmental aspects observable across childhood in order to outline core concepts that allow us to improve our analysis of these aspects. Said observable developmental aspects relate to the first affectionate bonds, a second stage of affectionate differentiations and a third stage of the discovery of otherness. These dimensions are pointed out as emergent in the frame of complex networks of nonlinear subjective constitution processes. These observable developmental aspects exist in the deep layers of our minds, coexist and transform along life. In this work, our descriptions focus on the first two dimensions. Our purpose is to highlight the importance of making diagnoses that account for what is established and its transformations, deficiencies and/or difficulties. Two basic assumptions guide this presentation: that in a person’s life, a diagnosis is never neutral; it is either therapeutic or iatrogenic, and that both development and trauma occur in an intersubjective relational dimension

Tramas de la constitución subjetiva y la complejidad del diagnóstico de niños desde un enfoque relacional / Paths of subjetive constitution and the complexity of child diagnosis from a relational approach

Este trabajo amplia uno precedente. Aporta al abordaje del diagnóstico y sus enlaces con las vicisitudes de la recomendación terapéutica; en términos de diferenciar entre dificultades por déficits, conflictos o reconstrucciones subjetivas en curso. Para trazar ejes conceptuales que delinean estas diferencias, como figura didáctica, puntualizamos observables evolutivos, organizados en torno a las primeras ligazones amorosas, un segundo tiempo de diferenciaciones amorosas y un tercero de descubrimiento de la alteridad del otro. Observables que se constituyen las capas profundas de la mente, coexisten y transforman a lo largo de la vida. En pos de señalar la importancia de elaborar diagnósticos que den cuenta de lo constituido y sus transformaciones, de déficits y/o dificultades nos focalizamos en la niñez. Dos supuestos básicos guían esta presentación; en la vida de una persona el diagnóstico nunca resulta neutro, es terapéutico o iatrogénico, tanto desarrollo como trauma devienen en la dimensión relacional intersubjetiva

This work expands one precedent. It contributes to the approach of the diagnosis and its links with the vicissitudes of the therapeutic recommendation; In terms of differentiating between difficulties due to ongoing deficits, conflicts or subjective reconstructions.As a didactic device, we decided to consider developmental aspects observable across childhood in order to outline core concepts that allow us to improve our analysis of these aspects. Said observable developmental aspects relate to the first affectionate bonds, a second stage of affectionate differentiations and a third stage of the discovery of otherness. These dimensions are pointed out as emergent in the frame of complex networks of nonlinear subjective constitution processes. These observable developmental aspects exist in the deep layers of our minds, coexist and transform along life. In this work, our descriptions focus on the first two dimensions. Our purpose is to highlight the importance of making diagnoses that account for what is established and its transformations, deficiencies and/or difficulties. Two basic assumptions guide this presentation: that in a person’s life, a diagnosis is never neutral; it is either therapeutic or iatrogenic, and that both development and trauma occur in an intersubjective relational dimension

Entornos multidisruptivos, traumatizantes y propiciadores de manifestaciones violentas en el mundo contemporáneo analizados desde investigaciones interrelacionadas / Multidisruptive, traumatizers and propiators of violent manifestations environmentsin the contemporary world analyzed from interrelated research

En este trabajos se presentan los principales resultados de investigaciones realizadas en Buenos Aires y San Luis (Argentina) y en Girona (España) sobre el potencial de los entornos multidisruptivos que al operar como traumatizantes propician las contemporáneas expresiones de violencias. Las indagaciones desarrolladas con muestras clínicas se respaldan en enfoques psicoanalíticos que retoman los aportes de la teoría del apego para ubicar la dimensión relacional como epicentro de la estructuración psíquica y entramados subjetivos. A través de la presente puesta en relación se procura brindar aportes viables de ser traducidos en el planteo de objetivos, métodos y programas de protección e intervención a ser implementados. Las conclusiones señalan que las manifestaciones de maltrato infantil y violencia tanto de niño como de adolescentes requieren ser abordadas considerando las vicisitudes relacionales con el o los adultos a cargo en el marco de la transmisión transgeneracional. En las poblaciones estudiadas se repite como factor común la reducida conciencia tanto de la intensidad del dolor psíquico implicado en la relación como de la alta vulnerabilidad a la que se encuentran expuestas. La intervención terapéutica temprana, diagnósticos diferenciales que sustenten abordajes específicos y seguimiento, constituyen un modo de encarar un proceso propiciador de cambio.

In this paper we intend to relate research carried out in Buenos Aires and San Luis (Argentina) and Girona (Spain) about the potential of multidisruptive environments that, when operating as traumatizers, induce contemporary expressions of violence. Research developed with clinical samples are base on psychoanalytic approaches that return the contributions of attachment theory to point out the relational dimension as the epicenter of psychic structuring and subjective frameworks. Viable contributions to the development of objectives, methods and programs of protection and intervention to be implemented will be provided through the present relationship. Conclusions point out that manifestations of child abuse and violence both of children and adolescents need to be approach considering the relational vicissitudes in the framework of transgenerational transmission with the adult (s) in charge. In the samples studied, a common factor is the reduced awareness of both the intensity of the psychic pain in the relationship as the high vulnerability they are exposed. Early therapeutic intervention, differential diagnoses that support specific approaches and follow-up, constitute a way to face a change process.

La Relación entre el Nivel Educativo de la Madre y el Rendimiento Cognitivo Infanto-Juvenil a partir del WISC-IV / The Relationship Between Maternal Educational Level and Infant-Juvenile Cognitive Performance Based on WISC-IV Scale

A efectos de explorar la relación entre rendimiento intelectual y nivel educativo materno, en el presente estudio piloto se analizan 50 díadas madre-hijo. El rendimiento cognitivo de los menores se evaluó a través de la Escala de Inteligencia para Niños de Wechsler -cuarta edición (WISCIV) en su adaptación argentina, y los años de educación materna a partir de un cuestionario sociodemográfico. Los resultados indicaron correlaciones significativas entre las dos variables evaluadas. De este modo, se constata la relevancia de la educación materna como predictor del rendimiento en el WISC-IV. Las conclusiones ratifican la necesidad de reconocer los factores socio-ambientales que rodean al sujeto para desarrollar una interpretación más completa de la producción registrada en el test.

This research paper aims to explore the relationship between intellectual performance and maternal educational level. 50 mother-child couples were sampled. To assess the children's cognitive performance, the Wechsler (4th edition (WISC-IV) scale and a demographic questionnaire of maternal education were used. The results showed significant correlations between the two variables. Consequently, maternal education as relevant performance predictor in WISC-IV scale is confirmed. The conclusions also prove the need to recognize socio-environmental factors around this subject to develop a more comprehensive interpretation related to the test results.

Costo-efectividad de linezolid comparado con vancomicina en el manejo de la neumonía asociada a ventilación mecánica en Colombia / Cost effectiveness of linezolid compared with vancomycin in the management of ventilator-associated pneumonia in Colombia

Objetivo: Estimar la costo-efectividad de linezolid versus vancomicina en el manejo de neumonía asociada a ventilación mecánica (NAV) causada por Staphylococcus aureus resistente a meticilina (SARM) en Colombia. Materiales y métodos: Se construyó un árbol de decisión para determinar la razón de costo-efectividad incremental de linezolid (600 mg iv/12 h) comparado con vancomicina (15 mg/kg iv/12 h) en el tratamiento de NAV por SARM. La perspectiva fue la del sistema de salud incluyendo solo costos directos. Todas las unidades monetarias se expresan en pesos colombianos del 2013 sin descuento (1 USD =$ 1.876,22). Se empleó un horizonte temporal de 30 días. Los resultados se midieron en proporción de pacientes curados. Los datos de eficacia y seguridad se tomaron de la literatura. Los costos de los procedimientos se obtuvieron del manual tarifario ISS del 2001, para medicamentos se utilizó el SISMED y la regulación de precios vigente. Se realizaron análisis de sensibilidad univariados y probabilísticos. Resultados: Los costos totales esperados por paciente curado fueron: $ 2.600.094 para linezolid y $ 1.992.753 para vancomicina. La proporción de pacientes curados fue: 53% con linezolid y 41%.con vancomicina. La razón de costo-efectividad de linezolid comparado con vancomicina fue $ 5.061.173 por paciente curado. Para cada alternativa, los resultados fueron sensibles a la probabilidad de éxito del tratamiento, a la probabilidad de presentar eventos adversos y al costo del tratamiento. Conclusión: En Colombia, linezolid sería una alternativa costo-efectiva en el tratamiento de NAV por SARM, para disponibilidades a pagar superiores a $ 5.061.173 por paciente curado.

Objective: To estimate the cost-effectiveness of linezolid versus vancomycin in the management of ventilator-associated pneumonia (VAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in Colombia. Materials and methods: We constructed a decision tree to determine the incremental cost effectiveness ratio (ICER) of linezolid (600 mg iv /12 h) compared to vancomycin (15 mg/kg iv/12 h) for the treatment of VAP caused for MRSA. The perspective is that of the Colombian health system, including only direct costs. All currency units are in Colombian pesos (COP, 2013) with no discount. (1 USD = $1,876.22). We used a time horizon of 30 days. The results were measured in the proportion of patients cured. The efficacy and safety data were taken from the literature. The costs of procedures were obtained of ISS tariff manual of 2001 and for drugs current price regulations and the SISMED database were used. Univariate and probabilistic sensitivity analyses were performed. Results: The total costs expected per patient cured were COP 2,600,094 for linezolid and COP 1,992,753 for vancomycin. The proportion of cured patients was 53% with linezolid and 41% with vancomycin. The ICER of linezolid compared with vancomycin was COP 5,061,173 per patient cured. For each alternative, the results were sensitive to the probability of the success of treatment, the probability of adverse events and the cost of treatment. Conclusion: Linezolid would be a cost-effective alternative in the treatment of VAP for MRSA in Colombia for willingness to pay above COP 5,061,173 per patient cured.

Costo-efectividad del tratamiento con interferón beta en pacientes con síndrome clínico aislado de alto riesgo en Colombia / The cost-effectiveness of interferon beta treatment in patients with a clinically isolated syndrome in Colombia

Introducción. En 85 % de los pacientes con esclerosis múltiple se presenta como manifestación inicial un primer evento desmielinizante o síndrome clínico aislado. En estos casos, el tratamiento con interferón beta retrasa hasta dos años la progresión a esclerosis múltiple. Sin embargo, en Colombia este medicamento es costoso. Objetivo. Determinar si el tratamiento del síndrome clínico aislado con interferón beta es costo-efectivo al retrasar la esclerosis múltiple en dos años. Materiales y métodos. Se realizó un análisis de costo-efectividad empleando un árbol de decisiones basado en la perspectiva del paciente y la sociedad. A partir de una revisión sistemática de la literatura y de conceptos de expertos se definieron las diversas probabilidades. Los costos de la enfermedad se calcularon por medio de la revisión de historias y la aplicación de encuestas a los pacientes atendidos en el Hospital Universitario San Ignacio. Para controlar la incertidumbre se realizó un análisis de sensibilidad mediante una simulación de Monte Carlo con mil pacientes. Resultados. El costo del tratamiento con interferón sobrepasa los Col$ 95´000.000 (US$ 50.000) por paciente durante los dos años. Aproximadamente, 80 % corresponde a los costos del medicamento. El costo de la recaída se acerca a Col$ 39´139.200 (US$ 21.744), y los costos indirectos corresponden a Col$ 10´958.400 (US$ 6.088). La tasa representativa del mercado fue de Col$ 1.800. Con el tratamiento se ganan sólo 0,06 años de vida ajustados por discapacidad (AVAD) adicionales. La razón de costo-efectividad ‘incremental´ (sic.) supera el umbral, incluso en el análisis de sensibilidad. Conclusión. La administración de interferón beta en pacientes con síndrome clínico aislado de alto riesgo en los primeros dos años no es costo-efectiva en Colombia.

Introduction: Approximately 85% of patients with multiple sclerosis have an initial demyelinating event. Treatment with interferon beta delays the progression of multiple sclerosis for nearly two years in patients with a clinically isolated syndrome. In Colombia, interferon is very expensive when compared to other countries. Objective: We sought to determine the cost-effectiveness of a two-year interferon beta treatment within Colombia in patients with a clinically isolated syndrome. Materials and methods: Based on patient and society perspectives, a cost-effectiveness analysis was conducted using a decision tree. A variety of probabilities were defined after a systematic review of the available literature. The disease costs were calculated by reviewing medical charts at the Hospital San Ignacio University and surveys completed by multiple sclerosis patients. To control for uncertainty in these data, analysis of approximately one-thousand patients was performed using Monte Carlo methods. Results: The two-year treatment cost per patient exceeds Col$ 95,000,000 (US$ 50,000). Approximately 80 % of this cost corresponds to medications (US$ 40,500). The price of relapse and indirect costs totals Col$ 41,632,149 (US$ 21,744) and Col$ 11,656,389 (US$ 6,088), respectively. Treatment represents an increase of 0.06 quality-adjusted life years (QALY). The incremental cost-effectiveness ratio exceeds the threshold, regardless of the use of Monte Carlo methods for analysis. Conclusion: Administering interferon beta over the course of two years to high-risk patients with a clinically isolated syndrome is not cost-effective within Colombia.