Costo-efectividad de tratamientos ambulatorios para la pérdida de peso, en adultos mexicanos / Cost-effectiveness in outpatient treatments for weight loss in Mexican adults

Resumen Objetivo: Identificar la mejor intervención costo-efectividad para el tratamiento de obesidad grado I y II, en el primer nivel de atención para población sin seguridad social, que requiera los servicios del Instituto de Salud y Bienestar (INSABI) Material y Métodos: Se realizó un análisis de costo-efectividad desde la perspectiva del proveedor. Se diseñaron y calcularon los costos de tres tratamientos para la obesidad I y II en usuarios del primer nivel de atención a la salud que carecen de seguridad social, en el municipio de Coatetelco, Morelos. Cada tratamiento fue estimado para el periodo de un año. Los indicadores de efectividad fueron obtenidos a través de estudios previos con características similares a las intervenciones diseñadas. Resultados: La intervención que presento un mayor costo, fue el tratamiento farmacológico con $88,899.26 USD, seguida del tratamiento nutricional con un costo de $31,647.57 USD y $57,189.49 USD en el tratamiento integral. El coeficiente de efectividad obtenido fue de 0.1906 para el tratamiento nutricional, seguido del tratamiento farmacológico con 0.2168 y 0.2531 en el tratamiento integral. Conclusiones: El tratamiento nutricional es la mejor intervención costo- efectividad en pacientes con obesidad grado I y II que carecen de seguridad social y que reciben seguimiento en el primer nivel de atención a la salud. La inversión en estos tratamientos puede contribuir a disminuir los factores de riesgo para el desarrollo de enfermedades crónicas en México.

Abstract Objective: To identify the most cost-effective intervention for the treatment of grade I and II obesity in the first level of care for a population without social security that requires the services of the Institute of Health and Wellbeing (INSABI). Material and Methods: A cost-effectiveness analysis was carried out from the provider's perspective. The costs of three treatments for obesity I and II in users of the first level of health care who lack social security were designed and calculated in the municipality of Coatetelco, Morelos. Each treatment was estimated for a period of one year. The effectiveness indicators were obtained through previous studies with characteristics similar to the designed interventions. Results: The intervention that presented the highest cost was drug treatment with $ 88,899.26 USD, followed by nutritional treatment with a cost of $ 31,647.57 USD and $ 57,189.49 USD in comprehensive treatment. The coefficient of effectiveness obtained was 0.1906 for nutritional treatment, followed by pharmacological treatment with 0.2168 and 0.2531 in comprehensive treatment. Conclusions: Nutritional treatment is the most cost-effective intervention in patients with grade I and II obesity who lack social security is nutritional treatment and who receive care at the first level of health care. Investing in these treatments can help reduce risk factors for the development of chronic diseases in Mexico.

Avaliação in vitro da rugosidade superficial de dois tipos de revestimentos do condicionador de tecido submetidos ao teste da escovação mecânica / Evaluation in vitro of superficial roughness of two tissue conditioner sealers submitted to mechanical brushing test

Objetivo: Avaliar in vitro a propriedade física de rugosidade superficial de dois tipos de revestimentos utilizados sobre o condicionador tecidual Dura Conditioner: o primer do silicone Quick Line e o primer com o silicone Quick Line. Sessenta corpos de prova do condicionador de tecido Dura Conditioner com as dimensões de 23x9x3 milímetros foram preparados de acordo com as normas dos fabricantes. Os revestimentos foram aplicados sobre a superfície de 40 corpos de prova enquanto 20 corpos de condicionador de tecido Dura Conditioner não receberam revestimento e formaram o grupo controle. Dos outros 40 corpos de prova do condicionador de tecido, 20 receberam o revestimento do primer do silicone Quick Line e 20 receberam o revestimento do primer, sobre o qual foi aplicado o silicone Quick Line. Todos os corpos de prova foram divididos em 2 grupos e armazenados em estufa a 37 graus centígrados, cada grupo por 7 e 14 respectivamente. Posteriormente, foram submetidos à leitura de rugosidade superficial em um rugosímetro. Os resultados foram submetidos à leitura de rugosidade superficial em um rugosímetro. Os resultados foram submetidos à análise de variância, sendo adotado um nível de significância de 0,05. Os corpos de prova que receberam apenas o revestimento de primer foram os que apresentaram em média a menor rugosidade superficial, estatisticamente significante, pós-escovação mecânica.Para se obter menor rugosidade superficial, a utilização do revestimento de primer apenas é a mais indicada.

ObjectiveThis in vitro study evaluated the physical property called superficial roughness,of two sealers used with the tissue conditioner Dura Conditioner®: the primer ofthe silicon Quick Line® and the primer with the silicon Quick Line®.MethodsSixty specimens of the tissue conditioner Dura Conditioner® (23 x 9 x 3 millimeters)were prepared according to the manufactures’ directions. Twenty of the tissueconditioner Dura Conditioner® were left without sealer and constituted the controlgroup. Sealers were applied on the surface of forty conditioner specimens, asfollows: Twenty were coated with the primer of the silicon Quick Line®; the othertwenty were coated with the primer and the silicon Quick Line®. All specimenswere separated in two groups, which were stored in water at 37°C for 7 and 14days and mechanically brushed for 777 and 1,554 cycles, respectively. Then, allspecimens were submitted to the reading of superficial roughness. Data from thetest were analysed statistically using analysis of variance it was performed, adoptinga significance level of p<0,05.ResultsAfter the mechanical brushing, the specimens that presented on average thesmallest superficial roughness, statistically significant, were the ones that hadbeen coated only with the primer.ConclusionFor small superficial roughness, the coat only with the primer is the best choice.

Paratireoidectomia subtotal no tratamento do hiperparatireoidismo secundário à doença renal crônica / Subtotal parathyroidectomy in the treatment of secondary hyperparathyroidism to chronic renal disease

Objetivos: apresentar os resultados obtidos com a paratireoidectomia (PTX) subtotal em pacientes com hiperparatireoidismo (HPT) secundário àinsuficiência renal crônica (IRC), enfocando a contribuição e as dificuldades técnicas da cirurgia. Pacientes e Métodos: no período de janeiro de 1998 ajunho de 2005 foram operados consecutivamente no Hospital Universitário Antonio Pedro, 33 pacientes renais crônicos portadores de HPT secundário. Ascirurgias foram realizadas pelo mesmo cirurgião e a mesma equipe de nefrologista se encarregou do controle pré e pós-operatório. Esse grupo foiconstituído por 19 homens e 14 mulheres com idade média de 40,5 (16/68) anos e todos se encontravam em tratamento dialítico regular, com tempo médiode diálise de 113 (20/189) meses. Além dos cuidados habituais, todos os pacientes receberam calcitriol após as três últimas sessões de diálise queantecederam a cirurgia. Resultados: os resultados mais expressivos se refletiram sobre o aparelho músculo-esquelético e foram muito significativas as remissões das queixas de dor ósteo-articular, fraqueza e prurido; as calcificações não vasculares foram reabsorvidas e sinais de remineralização ósseaforam identificados após a cirurgia. As complicações pós-operatórias mais freqüentes foram a rouquidão transitória (21%), a hiperpotassemia (12%) e osangramento pós-operatório (12%). Nesse grupo há uma recidiva comprovada e já reoperada e dois pacientes encontram-se em fase de investigação, por provável insucesso na cirurgia, já que o PTH continua elevado. Os resultados menos favoráveis foram mais freqüentes nos casos onde foram encontradas apenas três glândulas paratireóides. Não houve mortalidade operatória. Conclusões: a PTX subtotal pode ser realizada com segurança e é efetiva para a remissão de diversas manifestações do HPT secundário, desde que continuem sob rigoroso controle clínico para evitar possíveis recidivas por hiperplasia do resíduo glandular.

Objective: to report the results obtained with subtotal parathyroidectomy (PTX) in patients with hyperparathyroidism (HPT) secondary to chronic renaldisease (CRD), focusing on the contribution and technical difficulties of the surgery. Methods: From January of 1998 to June of 2005, thirty-three end-stagerenal disease (ESRD) patients consecutively underwent PTX in the university hospital. Their mean age was 40.5 years; Nineteen were male, and 14 female.Mean time on dialysis was 113 months. Surgeries were accomplished by the same surgeon and the same nephrologist was in charge of the pre- andpostoperative care of the whole patients. Among the clinical manifestations those related to the osteopathy were the most prevalent ones. All patientsunderwent preoperative care and received calcitriol after the last three dialysis sessions that preceded the surgery. Results: the most expressiveimprovements pertained to the muscle-skeletal system. The alleviation of bone pain, joint pain, muscle weakness and itch were marked. Extra-vascularcalcifications were reabsorbed and radiological signs of bone remineralization were identified after the surgery. The most frequent postoperativecomplications were temporary hoarseness (21%), hyperkalemia (12%), and postoperative bleeding (12%). So far, we have faced one proven recurrencethat was managed by a surgical reintervention. In addition, PTH continues to be high in two patients who are undergoing prepare for a new surgery. Bad results seemed to be more frequent on patients in which only three parathyroid glands were found during the operation. Surgery was not associated to fatalities. Conclusions: subtotal PTX can be accomplished with safety in ESRD patients being effective for the alleviation of several manifestations of the secondary HPT. Patients should be maintained under strict clinical control to monitor for recurrences due to hyperplasia of the residual glandular tissue.

Evolução da doença óssea após o transplante renal / Evolution of bone disease after renal transplantation: correlation between biochemical parameters and histopathological findings

Um transplante renal bem sucedido pode corrigir a maioria das anormalidades metabólicas que causam a osteodistrofia renal. Porém, crescentes evidências mostram que a doença óssea pode constituir um importante problema clínico após o transplante renal. Neste estudo, avaliou-se, prospectivamente, a evolução da doença óssea através da análise da histomorfometria óssea e de parâmetros laboratoriais de pacientes antes e após seis meses de um transplante renal bem sucedido. Ao todo, 25 pacientes (18M/7F), com idade mediana de 37 anos (20-58), foram incluídos no estudo. Vinte e três estavam em hemodiálise e 2, em CAPD; a duração mediana em diálise foi de 23 meses (9-88). Análise histomorfométrica das biópsias ósseas foi obtida em 20 pacientes. No pré-Tx, doze apresentavam doença adinâmica, 3, lesão mínima, 3, doença mista e 2, osteíte fibrosa. No pós-Tx, onze apresentavam doença adinâmica, 8, lesão mínima e 1, osteomalácía. Apesar de termos encontrado uma freqüência de doença óssea adinâmica comparável no pré e no pós-Tx, os pacientes acometidos nas 2 fases do estudo não eram exatamente os mesmos. Dos 12 casos de doença adinâmica no pré-Tx, 5 melhoraram a formação e mineralização óssea passando a lesão mínima, e sete, permaneceram como doença óssea adinâmica. Os pacientes com lesões relacionadas ao hiperparatireoidismo evoluíram com melhora ou resolução completa dessas alterações. Entretanto, cinco evoluíram com doenças de baixo turnover ósseo (4 com doença adinâmica e 1 com osteomalácia). Três dos 4 pacientes que evoluíram como adinâmicos apresentavam persistência dos depósitos de alumínio e/ou ferro em suas superfícies ósseas. 0 outro e aquele com osteomalácia apresentavam hipofosfatemia e PTHi elevado. Os parâmetros laboratoriais também tiveram uma tendência à normalização. Os dois únicos pacientes hipercalcêmicos no pós-Tx apresentavam doença óssea de baixo turnover. Após o Tx, o nível do magnésio caiu e o do cloro, aumentou. Os pacientes com valores normais de fosfatase alcalina óssea no pré-Tx evoluíram com aumento significante deste parâmetro. Não houve correlação entre fosfatase alcalina óssea e PTHi no pós-Tx. O PTHi reduziu-se significantemente naqueles com valores iniciais aumentados, poreém, 4 persistiram com PTHi acima do normal. No pós-Tx, não houve correlação da fosfatase alcalina óssea ou do PTHi com qualquer dos parâmetros histomorfométricos...

Parafusos reabsorvíveis: uso em cirurgia ortognática / Resorbable screws: utilization in orthognathic surgery

Os autores discutem a utilizaçäo de parafusos reabsorvíveis para fixaçäo interna rígida em cirurgia ortognática, apresentando um caso clínico de correçäo de uma deformidade dentofacial do tipo prognatismo mandibular. Foram analisados os polímeros sintéticos mais usados na formaçäo desses novos materiais reabsorvíveis, bem como suas propriedades, determinando-se as vantagens da sua utilizaçäo

Effects of in-center daily hemodialysis upon mineral metabolism and bone disease in end-stage renal disease patients

CONTEXT: Alternative hemodialysis schedules have been proposed to improve the quality of the dialysis. Nonetheless, their influence upon mineral and bone disorders is unknown. OBJECTIVE: To report the impact of a daily hemodialysis schedule upon the lesions of renal osteodystrophy. TYPE OF STUDY: Prospective non-controlled study. SETTING: Public University Hospital. PARTICIPANTS: Five patients treated by daily hemodialysis for at least 24 months. INTERVENTION: Daily dialysis sessions were accomplished with non-proportional dialysis machines without an ultrafiltration control device, with blood flow of 300 ml/min, bicarbonate dialysate ([Ca]=3.5 mEq/L) at 500 ml/min, and low-flux membrane dialyzers. Sessions were started at 6:00 p.m. (except Sundays) and lasted 2 hours. MAIN MEASUREMENTS: Serum levels of Ca and P from the last 6 months on conventional hemodialysis for the same patients were used for comparison with each semester of daily hemodialysis. Bone biopsies and PTH levels were obtained at the end of the conventional hemodialysis period and then again after 2 years of daily hemodialysis. RESULTS: Mean serum calcium was significantly higher during the second and third semesters of daily dialysis [10.0 mg percent (SD 0.6), and 10.0 mg percent (SD 0.8), respectively] compared to standard dialysis [9.4 mg percent (SD 0.8)], p < 0.05. Mean values for phosphorus were significantly lower during every semester of daily hemodialysis [6.3 mg percent (SD 1.8), 5.8 mg percent (SD 1.7), 6.0 mg percent (SD 1.7), and 6.0 mg percent (SD 1.8)] compared to standard dialysis [7.2 mg percent (SD 2.7)], P < 0.05. Variations in mean Ca x P product followed the same pattern as for phosphorus [59.5 (SD 16.0), 57.1 (SD 16.3), 59.8 (SD 17.7), and 58.31 (SD 20.9) vs. 68.6 (SD 27.3), P < 0.05]...

Calcium acetate versus calcium carbonate in the control of hyperphosphatemia in hemodialysis patients

CONTEXT: Hyperphosphatemia has an important role in the development of bone and mineral abnormalities in end-stage renal disease (ESRD). OBJECTIVE: To compare the phosphorus binding power and the hypercalcemic effect of calcium acetate and calcium carbonate in hemodialysis patients. TYPE OF STUDY: Crossover, randomized, double-blind study. PLACE: A private hospital dialysis center. PARTICIPANTS: Fifty-two patients who were undergoing regular hemodialysis three times a week ([Ca++] dialysate = 3.5 mEq/L). PROCEDURES: Half of the patients were started on 5.6 g/day of calcium acetate and, after a 2 week washout period, received 6.2 g/day of calcium carbonate. The other half followed an inverse protocol. MAIN MEASUREMENTS: Clinical interviews were conducted 3 times a week to monitor for side effects. Determinations of serum urea, calcium, phosphorus, hematocrit, Kt/V and blood gas analysis were obtained before and after each treatment. RESULTS: Twenty-three patients completed the study. A significant increase in calcium plasma levels was only observed after treatment with calcium carbonate [9.34 mg/dl (SD 0.91) vs. 9.91 mg/dl (SD 0.79), P < 0.01]. The drop in phosphorus levels was substantial and significant for both salts [5.64 mg/dl (SD 1.54) vs. 4.60 mg/dl (SD 1.32), P < 0.01 and 5.89 mg/dl (SD 1.71) vs. 4.56 mg/dl (SD 1.57), P < 0.01, for calcium acetate and calcium carbonate respectively]. The percentage reduction in serum phosphorus (at the end of the study) per milliequivalent of salt administered per day tended to be higher with calcium acetate but statistical significance was not found. CONCLUSION: Calcium acetate can be a good alternative to calcium carbonate in the handling of hyperphosphatemia in ESRD patients. When calcium acetate is used, control of hyperphosphatemia can be achieved with a lower administration of calcium, perhaps with a lower risk of hypercalcemia

The spectrum of bone disease in 200 chronic hemodialysis patients: a correlation between clinical, biochemical and histologic findings

Introduction: Renal osteodystrophy includes the complete range of mineral metabolism disordes that affect the skeleton in patients with chronic renal failure. Patients and Methods: 200 patients with end-stage renal disease and on dialysis were investigated regarding the clinical, biochemical and histological findings of bone disease. Results: The spectrum of renal osteodystrophy consisted mainly of high turnover bone lesions (74.5 percent), including osteitis fibrosa in 57.5 percent. Patients with mild bone disease were on dialysis for shorter periods of time and were mostly asymptomatic. Patients with aluminum-related bone disease (16.5 percent) had the greatest aluminum exposure, either orally or parenterally, and together with patients with high turnover mixed disease, were the most symptomatic. Although on a non-regular basis, the vast majority of the patients (82.5 percent) had been receiving vitamin D. The incidence of adynamic bone disease was high (n=8) among parathyroidectomized patients (n=12). Significantly higher serum levels of alkaline phosphatase were observed in osteitis fibrosa. Conclusions: The use calcitriol and phosphate-binding agents on a non-regular basis seems to be the reason for the apparent reduced response to the treatment of secondary hyperparathyroidism. Alkaline phosphatase has been shown to be a fair marker for bone turnover in patients with osteitis fiborsa. The severity of the clinical manifestations of bone disease correlates with the histological features of bone lesion and to the time spent on dialysis.