Costeo basado en actividades: una metodología de gestión en tratamientos intensivos / Activity-based costing methodology to manage resources in intensive care units

Background: An accurate estimation of resources use by individual patients is crucial in hospital management. Aim: To measure financial costs of health care actions in intensive care units of two public regional hospitals in Chile. Material and Methods: Prospective follow up of 716 patients admitted to two intensive care units during 2011. The financial costs of health care activities was calculated using the Activity-Based Costing methodology. The main activities recorded were procedures and treatments, monitoring, response to patient needs, patient maintenance and coordination. Results: Activity-Based Costs, including human resources and assorted indirect costs correspond to 81 to 88% of costs per disease in one hospital and 69 to 80% in the other. The costs associated to procedures and treatments are the most significant and are approximately $100,000 (Chilean pesos) per day of hospitalization. The second most significant cost corresponds to coordination activities, which fluctuates between $86,000 and 122,000 (Chilean pesos). Conclusions: There are significant differences in resources use between the two hospitals studied. Therefore cost estimation methodologies should be incorporated in the management of these clinical services.

Medicina intensiva en Chile: desafíos para su desarrollo. Documento de la Comisión Nacional de Medicina Intensiva del Ministerio de Salud / Ministry of Health Intensive Care Medicine Commission: Proposals for the development of the discipline

Intensive care medicine in Chile is still in its dawn. It has experienced a progressive growth in the last decade, but continues to be weak. Although investments in the discipline have increased fivefold, there is still a severe deficiency of intensive care specialists. This issue will represent a serious problem in the near future. The Ministry of Health gathered an expert committee to study the problem and propose solutions for the future development of the discipline.

Estudio retrospectivo de costos de tratamientos intensivos por paciente y día cama / Calculation of costs per inpatient day in an intensive care unit

Background: Intensive medicine is especially expensive and requires an efficient management. Aim: To measure the real costs of diseases treated in an intensive care unit and compare them with the costs assigned by the Chilean National Health Fund (FONASA) for 2008. Material and Methods: Retrospective review of 225 patients, representing 82 percent of discharges from an intensive care unit during 2008. Patients were classified according to their medical conditions as having sepsis, trauma, cardiovascular, respiratory or neurological diseases. Costs were calculated using the cost per activity system. Results: Trauma, sepsis and cardiovascular diseases had the greatest cost per inpatient day, corresponding to 294,779; 253,513 and 244,713 Chilean pesos, respectively. Seventy percent of costs correspond to human resources followed by complementary examinations, that represent up to 15 percent of costs. Patients with sepsis and cardiovascular diseases absorbed 28 and 26 percent of intensive care unit resources, respectively. Patients who died with these diseases absorbed 35 and 16 percent of resources, respectively. Conclusions: All diseases studied had significantly higher costs than those assigned by the National Health Fund.

Interaction between NO and oxytocin: influence on LHRH release

Nitric oxide synthase (NOS)-containing neurons have been localized in various parts of the CNS. These neurons occur in the hypothalamus, mostly in the paraventricular and supraoptic nuclei and their axons project to the neural lobe of the pituitary gland. We have found that nitric oxide (NO) controls luteinizing hormone-releasing hormone (LHRH) release from the hypothalamus acting as a signal transducer in norepinephrine (NE)-induced LHRH release. LHRH not only releases LH from the pituitary but also induces sexual behavior.On the other hand, it is known that oxytocin also stimulates mating behavior and there is some evidence that oxytocin can increase NE release. Therefore, it occurred to us that oxytocin may also stimulate LHRH releave via NE and NO. To test this hypothesis, we incubated medial basal hypothalamic (MBH) explants from adult male rats in vitro. Following a preincubation period of 30 min, MBH fragments were incubated in Krebs-Ringer bicarbonate buffer in the presence of various concentrations of oxytocin. Oxytocin relesed LHRH at concentrations ranging from 0.1 nM to 1muM with a maximal stimulatory effect (P<0.001) at 0.1 muM, but with no stimulatory effect at 10 muM. That these effects were mediated by NO was shown by the fact that incubation of the tissues with NG-monomethyl-L-arginine (NMMA), a competitive inhibitor of NOS, blocked the stimulatory effects. Furthermore, the release of LHRH by oxytocin was also blocked by prazocin, an alpha1-adrenergic receptor antagonist, indicating that NE mediated this effect. Oxytocin at the same concentrations also increased the activity of NOS (P<0.01) as measured by the conversion of [14C]arginine to citrulline, which is produced in equimolar amounts with NO by the action of NOS. The release of LHRH induced by oxytocin was also accompanied by a significant (P<0.02) increase in the release of prostaglandin E2 (PGE2), a mediator of LHRH release that is released by NO. On the other hand, incubation of neural lobes with vaious concentrations of sodium nitroprusside (NP) (300 or 600 muM), a releaser of NO, revealed that NO acts to suppres (P<0.01) the release of oxytoxin. Therefore, our results indicate that oxytocin releases LHRH by stimulating NOS via NE, resulting in an increased release of NO, which increases PGE2 release that in turn induces LHRH release. Furthermore, the released NO can act back on oxytocinergic terminals to suppress the release of oxytocin in an ultrashort-loop negative feedback.

Agentes causales de onicomicosis / [Causal agents of onychomycosis]

The results obtained with 307 specimens from putatively immunocompetent patients between May 1991 and May 1992 were reviewed, to determine the frequency of isolation of fungal species causing onychomycoses. Sixty eight percent of the specimen were positive for microscopic examination and/or cultures. Onychomycoses occurred with double frequency in women than in men (Table 1), and 77

of cases were diagnosed in patients aged between 30 and 70 years (Figure 1). Out of 182 patients with positive cultures, 60

were affected by dermatophytes and 39

by yeasts; molds (Aspergillus spp.) were isolated in only two cases (Table 3). Neither Corynebacterium spp., nor Malasezzia furfur were detected. In toe nails Trichophyton rubrum predominated over yeasts being isolated in 72.9

of the cases; yeasts other than Candida albicans were isolated in 12.3

, Trichophyton mentagrophytes in 10

, while Aspergillus spp., C. albicans and Epidermophyton floccosum in only 1.6

. On the other hand, in finger nails yeasts predominated: C. albicans was isolated in 46.7

of cases, other yeasts in 43.3

; and T. rubrum in the remaining 10

. Out of 41 isolations of yeasts other than C. albicans, 42

Trichosporum cutaneum and 6