Does diagnostic testing always decrease antibiotics prescriptions?

BACKGROUND: Empiric prescription to treat infectious diseases in community care settings has caused antibiotics to be overprescribed, increasing antimicrobial resistance (AMR). To reduce antibiotics prescription, the use of point-of-care diagnostic testing (POCT) has been suggested. METHODS: We present a stylized static theoretical economic model to analyse whether the use of POCT always decreases antibiotics prescriptions. We consider the interaction of a group of doctors who differ in their level of concern about AMR when prescribing with a firm selling a POCT, and we characterize the price set by the manufacturer and doctors' decision to employ POCT. RESULTS: We found that the number of antibiotics prescriptions is not always lower. This result depends on the distribution of the doctors' concern about AMR as there is a proportion of doctors who use POCT and then prescribe antibiotics while other doctors change their prescribing behaviour after using POCT and stop giving antibiotics to patients who do not benefit from them. When the proportion of patients who need antibiotic treatment is higher than the proportion of doctors who use POCT and stop prescribing unnecessary antibiotics, the number of antibiotics prescriptions is larger. Our analysis also shows that the use of POCT improves health outcomes. CONCLUSIONS: We should be very careful when we assert that POCT reduces antibiotics prescriptions as there are situations in which the opposite effect occurs.

The "new normal" osmotic threshold: Osmostat reset.

Hyponatremia is the most common electrolyte disorder in hospitalized patients. The syndrome of inappropriate antidiuresis (SIAD) is one of the leading causes of hyponatremia. Although not widely known, SIAD has a vast spectrum of etiologies and differential diagnoses and has been classically divided into four types (A, B, C, D). Frequently, when we use the term SIAD in clinical practice, it refers to subtype A, the so-called classic SIAD. The purpose of reporting this case is to make the clinicians aware of a specific subtype of SIAD, type C, an underdiagnosed entity called osmostat reset (OR). Due to similarities, OR often ends up being misinterpreted as classic SIAD. However, the differentiation between these two entities is crucial due to treatment implications. This manuscript highlights the use of an algorithm, based on the fraction of uric acid excretion, as an approach to the differential diagnosis of hyponatremia.

Characterization and comparison of commercial oils used for human embryo culture.

STUDY QUESTION: Are there significant differences between the available commercial oil brands used for human IVF? SUMMARY ANSWER: Important differences have been detected among the tested oil brands in their potential to stabilize culture conditions and, more importantly, in their direct effect on embryo development and viability. WHAT IS KNOWN ALREADY: Mineral oil is a critical component of the human culture system due to its protective and stabilizing roles during in vitro embryo development. Many different oils are available on the market, with differences in their viscosity, density and overall quality. STUDY DESIGN, SIZE, DURATION: Thirteen different commercial oil brands were compared. PARTICIPANTS/MATERIALS, SETTING, METHODS: Each oil was firstly analyzed to assess its viscosity, density, peroxide value and potential oxidation. Secondly, the capacity of each oil to reduce pH, osmolality and temperature fluctuations during embryo culture and manipulation was compared. Lastly, a sensitive mouse embryo assay (MEA) protocol, previously optimized to detect toxicity in oils samples, was used to compare the overall quality of the different brands in terms of embryo developmental rates up to the blastocyst stage. At the end of the MEAs, a triple labeling protocol was applied to analyze Oct4+ cells, apoptotic cells and total cell counts in the blastocysts obtained by fluorescence microscopy. MAIN RESULTS AND THE ROLE OF CHANCE: Significant divergences were detected in the rise of osmolality and the equilibration and stability of pH between different oils, which could be correlated to their physico-chemical characteristics. In particular, oil samples with a higher viscosity tended to offer an additional protection against fluctuations in the culture conditions, however, the differences in temperature stability between oils were minor. Two out of the 13 oil samples, which were commercially available, were identified as embryo-toxic by applying the MEA protocol with increased sensitivity for toxicity detection. Additionally, substantial differences in the total number of cells and the number of cells in the inner cell mass of the obtained blastocysts were also detected between oil groups. LIMITATIONS, REASONS FOR CAUTION: A single lot of oil was used for each brand and, thus, lot-to-lot variations in oil quality could not be determined. However, several bottles from the same oil were included to account for potential intra-lot variability. WIDER IMPLICATIONS OF THE FINDINGS: Commercial oils differ in both their physical characteristics and their performance in maintaining the stability of the culture conditions during in vitro embryo culture. Oil selection is important for embryo culture success. Additionally, the detection of embryo-toxic oils which had already been released to the human IVF market showcases the importance of applying sensitive MEA protocols for a better detection of toxicity in this type of samples. STUDY FUNDING/COMPETING INTEREST(S): This study was privately funded. TRIAL REGISTRATION NUMBER: N/A.

Using point-of-care diagnostic testing for improved antibiotic prescription: an economic model.

BACKGROUND: Antibiotics have been overprescribed to treat infectious diseases and have generated antimicrobial resistances that reduce their effectiveness. Following the rationale behind the new paradigm of personalized medicine, point-of-care diagnostic testing (POCT) has been proposed to improve the quality of antibiotic prescription with the aim of reducing antimicrobial resistances. METHODS: In order to understand whether this recommendation is valid, we create a theoretical economic model to determine under which conditions the expected benefits of using POCT to guide antibiotic prescription are greater than for empiric prescription, where we define the expected benefits as the difference between the economic value of health and the costs of the treatment. We consider the interaction of a group of physicians who express differing levels of uncertainty when prescribing with a firm selling a diagnostic device, and analyse the firm's pricing policy and the physicians' prescribing decisions. We allow the physicians to internalize the external costs of antimicrobial resistances. RESULTS: We find that the use of POCT reduces the number of antibiotic prescriptions. The reduction in antibiotic prescriptions is higher when physicians internalise the costs of antimicrobial resistances. Physicians with relatively high levels of uncertainty use POCT as they are uncertain about the right treatment for a large proportion of patients. Physicians with low levels of uncertainty prefer to prescribe empirically. The segmentation in the population of physicians regarding the uptake of POCT depends on the distribution of levels of uncertainty across physicians. For each test, the firm charges the marginal production costs of the inputs needed to administer the test, and makes its profit from the sales of the testing devices. CONCLUSIONS: From a theoretical perspective, our findings corroborate the fact that POCT improve the quality of antibiotic prescription and reduce the number of prescriptions. Nevertheless, their use is not always recommended as empiric therapy may be preferred when uncertainty is low.

Mesotelioma pleural por exposición indirecta al asbesto en paciente anciana / Pleural mesothelioma by indirect exposure to asbestos in an elderly patient

Se describe el caso de una paciente de 93 años que fue ingresada por mesotelioma pleural de tipo linfoepitelial, atribuido a la exposición indirecta a fibras de asbesto procedente del lavado de la ropa de su marido, con un largo periodo de latencia. Se revisa la exposición ocupacional al asbesto y su baja incidencia en mujeres, más frecuente en estos casos por exposición indirecta o medioambiental. Se concluye con la necesidad de efectuar una correcta anamnesis para valorar los factores de riesgo de exposición, aun con largo tiempo de latencia

We describe the case of a 93-year-old patient who was diagnosed with lymphoepithelial-type pleural mesothelioma, attributed to indirect exposure to asbestos fibers from washing her husband's clothes, with a long latency period, reviewing occupational exposure to asbestos and its low incidence in women, more frequent in these cases due to indirect or environmental exposure. It concludes with the need to carry out a correct anamnesis to assess the risk factors of exposure even with a long latency time

Pre-approval incentives to promote adoption of personalized medicine: a theoretical approach.

BACKGROUND: Currently, personalised medicine is becoming more frequently used and many drug companies are including this strategy to gain market access for very specialized therapies. In this article, in order to understand the relationships between the health authority and the drug company when deciding upon the implementation of personalized medicines, we take a theoretical perspective to model it when the price and reimbursement policy follows a pay-for-performance scheme. During the development of a new drug, the firm must decide whether to generate additional knowledge by investing in additional resources to stratify the target population based on a biomarker or directly apply for marketing authorization for the new treatment without information on the characteristics of patients who could respond to it. In this context, we assume that the pricing policy is set by the health authority, and then we characterize the pricing and investment decisions contingent on the rate of response to the treatment. RESULTS: We find that the price when the firm carries out R&D leading to the personalized treatments is not necessarily higher than the price if the firm does not carry out the R&D investment. When the rate of response to the treatment is too low, then the new drug is not marketed. If the rate of response is too high, personalized medicine is not implemented. For intermediate values of the rate of response, the adoption of personalized medicine may occur if the investment costs are sufficiently low; otherwise, the treatment is given to all patients without additional information on their characteristics. The higher the quality of the genetic test (in terms of its sensitivity and specificity), the wider the interval for the values of the proportional responders for which personalized medicine may be implemented. CONCLUSIONS: Our findings show that pre-approval incentives (prices) to promote the personalized treatments depend on the specific characteristics of the disease and the efficacy of the treatment. The model gives an intuitive idea about what to expect in terms of price incentives when the possibility of personalizing treatments becomes a strategic decision for the stakeholders.

Endogenous versus exogenous generic reference pricing for pharmaceuticals.

In this paper we carry out a vertical differentiation duopoly model applied to pharmaceutical markets to analyze how endogenous and exogenous generic reference pricing influence competition between generic and branded drugs producers. Unlike the literature, we characterize for the exogenous case the equilibrium prices for all feasible relevant reference prices. Competition is enhanced after the introduction of a reference pricing system. We also compare both reference pricing systems on welfare grounds, assuming two different objective functions for health authorities: (i) standard social welfare and (ii) gross consumer surplus net of total pharmaceutical expenditures. We show that regardless of the objective function, health authorities will never choose endogenous reference pricing. When health authorities are paternalistic, the exogenous reference price that maximizes standard social welfare is such that the price of the generic drug is the reference price while the price of the branded drug is higher than the reference price. When health authorities are not paternalistic, the optimal exogenous reference price is such that the price of the branded drug is the reference price while the price of the generic drug is lower than the reference price.

Efectos de la imitación en la interacción social recíproca en un niño con Trastorno del Espectro Autista Grave / Effects of imitation on mutual social interaction in children with severe autism spectrum disorder / Efectes de la imitació en la interacción social recíproca en un nen amb trastorns de l'espectre autista greu

Los niños con trastorno del espectro autista (TEA) presentan dificultades de empatía y relación social. Estudios previos sugieren un déficit primario en el sistema de neuronas espejo. En este estudio de caso único se ha aplicado la metodología observacional para investigar el uso de la imitación en un proceso de una psicoterapia de orientación psicoanalítica en un niño con TEA grave. Los resultados sugieren que el uso de la imitación en este tipo de psicoterapia es una opción recomendable, ya que favorece los procesos de diferenciación y mejora las capacidades de interacción

Children with autism spectrum disorders (ASD) show difficulties in empathy and social interaction. Previous studies suggest primary deficits in the mirror system brain network. In this single case study observational methodology has been used to investigate the process of a psychoanalytic psychotherapy with imitation in a child with severe ASD. Results suggest that the use of imitation within this psychotherapy approach promote the differentiation processes and stimulates social interaction

Efectes de la imitació en la interacció social recíproca en un nen amb trastorn de l’espectre autista greu. Els nens amb trastorn de l’espectre autista (TEA) presenten dificultats d’empatia i relació social. Estudis previs suggereixen un dèficit primari en el sistema de neurones mirall. En aquest estudi de cas únic s’ha aplicat la metodologia observacional per investigar l’ús de la imitació en un procés d’una psicoteràpia d’orientació psicoanalítica en un nen amb TEA greu. Els resultats suggereixen que l’ús de la imitació en aquest tipus de psicoteràpia és una opció recomanable, ja que afavoreix els processos de diferenciació i millora les capacitats d'interacció

Some economics on personalized and predictive medicine.

OBJECTIVE: To contribute to the theoretical literature on personalized medicine, analyzing and integrating in an economic model, the decision a health authority faces when it must decide on the implementation of personalized medicine in a context of uncertainty. METHODS: We carry out a stylized model to analyze the decision health authorities face when they do not have perfect information about the best treatment for a population of patients with a given disease. The health authorities decide whether to use a test to match patients with treatments (personalized medicine) to maximize health outcomes. Our model characterizes the situations under which personalized medicine dominates the alternative option of business-as-usual (treatment without previous test). We apply the model to the KRAS test for colorectal cancer, the PCA3 test for prostate cancer and the PCR test for the X-fragile syndrome, to illustrate how the parameters and variables of the model interact. RESULTS: Implementation of personalized medicine requires, as a necessary condition, having some tests with high discriminatory power. This is not a sufficient condition and expected health outcomes must be taken into account to make a decision. When the specificity and the sensitivity of the test are low, the health authority prefers to apply a treatment to all patients without using the test. When both characteristic of the test are high, the health authorities prefer to personalize the treatments when expected health outcomes are better than those under the standard treatment. When we applied the model to the three aforementioned tests, the results illustrate how decisions are adopted in real world. CONCLUSIONS: Although promising, the use of personalized medicine is still under scrutiny as there are important issues demanding a response. Personalized medicine may have an impact in the drug development processes, and contribute to the efficiency and effectiveness of health care delivery. Nevertheless, more accurate statistical and economic information related to tests results and treatment costs as well as additional medical information on the efficacy of the treatments are needed to adopt decisions that incorporate economic rationality.

Síndrome de Rapunzel: tratamiento laparoscópico / Rapunzel syndrome: Laparoscopic treatment

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Los servicios para las demencias en Escocia: De la voluntad política a la realidad clínica / No disponible

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Traumatismo hepático muy grave en la infancia. A propósito de dos casos con tratamiento mínimamente invasivo / Very severe hepatic trauma in childhood. the report of two cases with minimally invasive treatment

Los traumatismos hepáticos en los niños son una patología que presenta una incidencia creciente debido fundamentalmente a que cada vez los menores se ven más implicados en juegos y deportes de aventura, potencialmente peligrosos, y a los constantes accidentes de automóvil. Tradicionalmente el tratamiento es conservador, con soporte vital especializado y reposo absoluto, fundamentalmente. Ello permite en la mayoría de los casos una recuperación completa del paciente sin la agresión de la intervención quirúrgica, lo que previene, además, el daño sobreañadido de la manipulación de la víscera hepática lesionada. Presentamos dos casos clínicos de sendos niños de 6 y 4 años que sufrieron rotura traumática muy grave de hígado, intervenidos quirúrgicamente mediante técnicas mínimamente invasivas que lograron la curación completa (AU)

Liver trauma in children is a pathology that has an increasing incidence mainly due to the implications of growing children in hazardous games and sports adventure, and the frequent car accidents. There has been a shift of management in haemodynamically stable patients towards non-operative management. This allows in most cases a patient’s complete recovery without surgical aggression, preventing further damage derived from the handling of the injured liver. Here with we report two cases of a 6 and 4 year old boys who suffereda very severe traumatic rupture of the liver. They were operated through minimally invasive surgical procedures, achieving complete resolution of the serious damages (AU)

[Very severe hepatic trauma in childhood. The report of two cases with minimally invasive treatment]. / Traumatismo hepático muy grave en la infancia. A propósito de dos casos con tratamiento mínimamente invasivo.

Liver trauma in children is a pathology that has an increasing incidence mainly due to the implications of growing children in hazardous games and sports adventure, and the frequent car accidents. There has been a shift of management in haemodynamically stable patients towards non-operative management. This allows in most cases a patient's complete recovery without surgical aggression, preventing further damage derived from the handling of the injured liver. Herewith we report two cases of a 6 and 4 year old boys who suffered a very severe traumatic rupture of the liver. They were operated through minimally invasive surgical procedures, achieving complete resolution of the serious damages.

Utilización de dermis artificial en el manejo de heridas traumáticas con exposición ósea y/o tendinosa en niños / Use of artificial dermal matrix in the management of traumatic wounds with exposed bone and/or tendon in children

En los últimos años ha aumentado el uso de dermis artificial (Integra®) en niños, siendo su principal indicación la reconstrucción cutánea tras una quemadura o una extirpación de lesiones congénitas. Su uso en heridas traumáticas en niños es todavía poco frecuente, con escasas referencias en la bibliografía. Recientemente hemos utilizado dermis artificial en tres pacientes de 7, 9 y 13 años de edad, que presentaban heridas traumáticas en el miembro inferior izquierdo, el miembro inferior derecho y la región frontal, respectivamente. En todos los casos existía una importante pérdida de sustancia con exposición ósea y/o tendinosa. La dermis artificial se colocó entre los días 7 y 10 de evolución, siguiendo el protocolo habitual, tras el desbridamiento quirúrgico de las lesiones. En los tres casos la evolución ha sido satisfactoria, sin complicaciones y con unos buenos resultados estéticos y funcionales. El uso de dermis artificial en el caso de heridas traumáticas, con una importante pérdida de sustancia y exposición ósea y/o tendinosa, debe considerarse como una alternativa a los injertos de piel parcial o total, a los expansores tisulares e incluso a las transferencias de tejidos. En este tipo de heridas recomendamos la aplicación diferida de la dermis artificial (AU)

In recent years, the use of artificial dermal matrix (Integra®) in children has increased, being its main indication skin reconstruction after burn or removal of congenital lesions. Its use in traumatic wounds in children is rare, with few references in the literature. Recently, we have used artificial dermal matrix in 3 patients of 7, 9 and 13 years of age that presented traumatic wounds in left lower limb, right lower limb and frontal region respectively. In all cases there were important tissue defects with exposed bone and/or tendon. The artificial dermal matrix was applied between the 7th and 10th day of evolution, following the usual protocol, after surgical debridement of the wounds. In all 3 cases the evolution has been satisfactory, without complications and with good aesthetic and functional results. The use of artificial dermal matrix (Integra®) in cases of traumatic wounds, with important tissue subsastances and exposed bone and/or tendon, must be considered as an alternative to split or full thickness skin grafting, skin expansion and even skin flaps. We recommend in these wounds the deferred application of artificial dermal matrix (AU)

Hiperhidrosis palmar en la infancia: simpaticolisis toracoscópica y encuesta de satisfacción / Palmar hyperhidrosis in childhood: thoracoscopic sympathectomy

Introducción. El sudor excesivo en las manos, conocido como hiperhidrosis palmar, es un problema que comienza en la infancia y que a los niños les ocasiona una afectación importante, debido al fuerte impacto negativo en su calidad de vida por el permanente rechazo por parte de sus compañeros de juego. Además, la permanente humedad delas palmas de las manos interfiere con sus actividades escolares, juegos y deportes de contacto. Material y Método. Presentamos la técnica quirúrgica, de realización fácil, simple, segura y que mejores resultados ha demostrado aportar: la simpaticolisis toracoscópica. Exponemos nuestra casuística de los últimos 5 años junto con una encuesta de satisfacción realizada a todos los pacientes. Resultados. Hemos tenido resultados excelentes en el 100% de (..) (AU)

Background. Excessive hand sweating, known as palmar hyperhidrosis, is a disabling disorder that starts during the childhood, and can have a strong negative impact on the quality of life of affected children, as they feel rejected by others due to their permanently damp hands, suffering during school activities, contact sports and daily games. Material and Methods. Thoracoscopic sympathicolysis is easy to perform and has proven to be safe, with a short operating time. A review was performed on 48 children who underwent surgical treatment of palmar hyperhidrosis and answered a follow-up questionnaire to evaluate their level of satisfaction. Results. Considering the final surgical results, the 48 patients were completely satisfied with the outcome of the operation. Significant complications or adverse effects were not detected. Conclusions. The primary palmar hyperhidrosis is a pathology that entails an important reduction in the quality of life of those who suffer it. With the results of this technique in hand, we recommend the endoscopic thoracic sympathicolysis procedure for the treatment of this pathology in paediatrics. The level of patient satisfaction was high (AU)

[Palmar hyperhidrosis in childhood: thoracoscopic sympathectomy]. / Hiperhidrosis palmar en la infancia: simpaticolisis toracoscópica y encuesta de satisfacción.

BACKGROUND: Excessive hand sweating, known as palmar hyperhidrosis, is a disabling disorder that starts during the childhood, and can have a strong negative impact on the quality of life of affected children, as they feel rejected by others due to their permanently damp hands, suffering during school activities, contact sports and daily games. MATERIAL AND METHODS: Thoracoscopic sympathicolysis is easy to perform and has proven to be safe, with a short operating time. A review was performed on 48 children who underwent surgical treatment of palmar hyperhidrosis and answered a follow-up questionnaire to evaluate their level of satisfaction. RESULTS: Considering the final surgical results, the 48 patients were completely satisfied with the outcome of the operation. Significant complications or adverse effects were not detected. CONCLUSIONS: The primary palmar hyperhidrosis is a pathology that entails an important reduction in the quality of life of those who suffer it. With the results of this technique in hand, we recommend the endoscopic thoracic sympathicolysis procedure for the treatment of this pathology in paediatrics. The level of patient satisfaction was high.