Cost-effectiveness Analysis with Influence Diagrams.

BACKGROUND: Cost-effectiveness analysis (CEA) is used increasingly in medicine to determine whether the health benefit of an intervention is worth the economic cost. Decision trees, the standard decision modeling technique for non-temporal domains, can only perform CEA for very small problems. OBJECTIVE: To develop a method for CEA in problems involving several dozen variables. METHODS: We explain how to build influence diagrams (IDs) that explicitly represent cost and effectiveness. We propose an algorithm for evaluating cost-effectiveness IDs directly, i.e., without expanding an equivalent decision tree. RESULTS: The evaluation of an ID returns a set of intervals for the willingness to pay - separated by cost-effectiveness thresholds - and, for each interval, the cost, the effectiveness, and the optimal intervention. The algorithm that evaluates the ID directly is in general much more efficient than the brute-force method, which is in turn more efficient than the expansion of an equivalent decision tree. Using OpenMarkov, an open-source software tool that implements this algorithm, we have been able to perform CEAs on several IDs whose equivalent decision trees contain millions of branches. CONCLUSION: IDs can perform CEA on large problems that cannot be analyzed with decision trees.

Calidad de vida relacionada con la salud en la diabetes mellitus tipo 1 / Health related quality of life in type 1 diabetes mellitus

Introducción: El impacto diario del tratamiento de la DM1 en los aspectos psicosociales de los pacientes, demostrado científicamente, y la necesidad de un abordaje preventivo y educativo en los procesos de cuidado de esta enfermedad crónica llevan a considerar la importancia del estudio de la calidad de vida relacionada con la salud (CVRS) durante las etapas de la infancia y la adolescencia. Objetivos: a) Evaluar las dimensiones de la CVRS más afectadas por la enfermedad, y b) determinar su variación en función del período escolar, el sexo y el número de años de diagnóstico. Material y método: Estudio descriptivo de carácter aplicado. La muestra la constituyen 126 pacientes de 6 a 18 años con DM1, controlados en 4 hospitales públicos de Extremadura. El cuestionario de medida de la CVRS aplicado es la versión española del EQ-5D-Y.ResultadosLa dimensión más afectada para el total de la muestra es la ansiedad/depresión, con una diferencia significativa en el grupo de adolescentes (p=0,004). Conclusiones: Es necesario considerar la CVRS en la etapa de la adolescencia, poniendo especial atención al ámbito psicosocial en la propuesta de tratamiento y en el diseño de intervenciones educativas(AU)

Introduction: The daily impact of DM1 treatment on the psychological aspects of patients, scientifically proven, and the need for preventive and educational approaches in the care processes of this chronic disease, leads to consider the importance of studying the health-related quality of life (HRQOL) during the childhood and adolescence stages. Objectives: a) To assess the dimensions of HRQoL most affected by the disease, and b) to determine its variation as a function of the school year, sex and number of years from diagnosis. Material and method: An applied-descriptive study was used. The sample consisted of 126 patients from 6 to 18 years with type 1 diabetes, controlled in four public hospitals in Extremadura. The questionnaire measuring HRQoL is the Spanish version of EQ-5D-Y.ResultsThe most affected dimension for the total sample is anxiety/depression, with a significant difference in the adolescent group (P=0.004). Conclusions: It is necessary to consider the HRQOL assessment should be considered in adolescence, with special attention to the psychological aspects in the proposed treatment and design of educational interventions(AU)

[Health related quality of life in type 1 diabetes mellitus]. / Calidad de vida relacionada con la salud en la diabetes mellitus tipo 1.

INTRODUCTION: The daily impact of DM1 treatment on the psychological aspects of patients, scientifically proven, and the need for preventive and educational approaches in the care processes of this chronic disease, leads to consider the importance of studying the health-related quality of life (HRQOL) during the childhood and adolescence stages. OBJECTIVES: a) To assess the dimensions of HRQoL most affected by the disease, and b) to determine its variation as a function of the school year, sex and number of years from diagnosis. MATERIAL AND METHOD: An applied-descriptive study was used. The sample consisted of 126 patients from 6 to 18 years with type 1 diabetes, controlled in four public hospitals in Extremadura. The questionnaire measuring HRQoL is the Spanish version of EQ-5D-Y. RESULTS: The most affected dimension for the total sample is anxiety/depression, with a significant difference in the adolescent group (P=.004). CONCLUSIONS: It is necessary to consider the HRQOL assessment should be considered in adolescence, with special attention to the psychological aspects in the proposed treatment and design of educational interventions.

[Advertising and feeding: influence of graphical advertisements on dietary habits during childhood and adolescence]. / Publicidad y alimentación: influencia de los anuncios gráficos en las pautas alimentarias de infancia y adolescencia.

BACKGROUND AND OBJECTIVES: An optimal nutritional diet, especially during the infancy and adolescence, is an important social objective, to create habits and behaviours that will maintain during the adult life of the present children. The objective of this study is to collect and evaluate the publicity of nutritional products and how this is directed to children, before the approval of the codex of regulation of the publicity of nutritional products as directed to minors, prevention of obesity and health (codex PAOS) and after the start of the codex. SETTING, MATERIALS AND METHODS: To watch and collect data from commercials of nutritional products, such as transmitted by television during the infant programs. RESULTS: The obtained results show a great discrepancy between the diet constituted by the commercials for nutritional products and a diet, normally recommended for children. Besides this, nos changes in the commercials were noticed after the start of the codex. CONCLUSION: The commercials for nutritional products with a very high caloric value are transmitted to children during the infant programs are not appropriate for an optimal diet. The start of the Codex PAOS did not have much effect in the amount and quality of the commercials of nutritional products, such as directed to the infant public.

Incidence of Type 1 diabetes in children in Cáceres, Spain, during 1988-1999.

AIM: To determine the incidence of Type 1 diabetes in Cáceres in children less than 14 years of age. We tested for differences in incidence by age, sex and season at diagnosis. METHODS: All Type 1 diabetes cases with onset <14 years of age between 1988 and 1999 were recorded retrospectively. Pediatric Unit registries provided the primary source of ascertainment. The secondary independent data source was based on the registries of local Diabetic Associations, diabetes camp records and guarantee cards of blood-glucose meters. We used the capture-recapture method for ascertainment. RESULTS: During the 12-year period, 137 new cases of Type 1 diabetes were identified. Completeness of ascertainment was 99.2%. Average annual observed incidence was 16.8/100,000/year (95% C.I. 14.1-19.8). Age-standardised incidence (world population): 16.5/100,000/year (95% C.I. 13.9-19.6). Average annual incidence for 0-4, 5-9 and 10-13-year-old groups: 12.7/100,000 (95% C.I. 8.8-17.9), 18.2/100,000 (95% C.I. 13.7-23.8) and 19.1/100,000 (95% C.I. 14.2-25.1). The highest age-specific annual incidence rate was found in the 10-13-year age group. There was a seasonal onset pattern, with the highest incidence in autumn and winter. November was the month with the highest number of cases (22/137). CONCLUSION: Cáceres has a moderately high incidence of Type 1 diabetes in children less than 14 years of age, similar to that found in other more developed and densely populated regions of Spain, and in the range of other countries of northern Europe. These data do not support the hypothesis of a decrease in the incidence of the disease from north to south over Europe.

[Medical and surgical management of noniatrogenic traumatic tracheobronchial injuries]. / Manejo médico-quirúrgico de las lesiones traqueobronquiales traumáticas no iatrogénicas.

OBJECTIVE: To describe the medical and surgical management of noniatrogenic traumatic tracheobronchial injuries. PATIENTS AND METHOD: From January 1993 to July 2004, 15 cases of traumatic tracheobronchial injury were treated in our department. The diagnosis was established by bronchoscopy and a computed tomography chest scan was performed on all patients. Surgical treatment was selected for patients with unstable vital signs, an open tracheal wound, associated esophageal lesions, progression of subcutaneous or mediastinal emphysema, mediastinitis or suspicious mediastinal secretions on imaging tests, or difficulties with mechanical ventilation due to the traumatic tracheobronchial injury. RESULTS: The mean (SD) age of the patients was 35.5 (18.9) years and 12 (80%) were male. Of the 15 cases, 13 (86.7%) had penetrating trauma and 2 (13.3%) blunt trauma. The most common location of the injury was in the bronchi (9 cases; 60%), followed by the cervical trachea (4 cases; 26.6%), followed by both the thoracic trachea and bronchi (2 cases; 13.4%). The most common initial symptom was subcutaneous emphysema, which presented in 11 (73.3%) patients. Chest (12 cases; 86.7%) and orthopedic injuries (9 cases; 60%) were the most common associated injuries. Surgery was the treatment of choice in 11 (73.3%) cases and conservative medical treatment in 4 (26.7%). An irreversible brain injury caused the death of 1 patient receiving conservative treatment. CONCLUSIONS: Tracheobronchial injuries may be treated conservatively if they meet strict selection criteria. Size and location should not be used as selection criteria for surgical treatment.

[Importance of routine mediastinal staging in women with non-small cell lung cancer]. / Importancia de la estadificación mediastínica, sistemática en mujeres con carcinoma broncogénico, no microcítico.

OBJECTIVE: To study the specific importance of mediastinal staging in women with nonsmall cell lung cancer. PATIENTS AND METHODS: Between July 1981 and September 2003 we surgically staged 2172 patients with nonsmall cell lung cancer who met the inclusion criteria for resectability and operability. A subgroup of 108 women was studied. Cervical mediastinoscopy was performed in all cases, with the addition of anterior mediastinotomy in cases with left upper lobe involvement. All patients underwent a preoperative computed tomography chest scan. RESULTS: Cervical mediastinoscopy was performed on all 108 patients, 26 of whom also underwent anterior mediastinotomy. Positive findings were recorded in 44 (40.7%) of the 108 cases: 39 of the 108 mediastinoscopies (36.1%), 9 of the 26 mediastinotomies (34.6%), and in 5 cases (19.2%) both mediastinoscopy and mediastinotomy. Nodal involvement was found in 13% of cases in clinical stage IA and 30.8% of cases in clinical stage IB. The percentage of positive findings was significantly higher for cases with adenocarcinoma or large cell carcinoma (P<.05). We performed 67 thoracotomies: 46 patients underwent lobectomy (42.6% of the 108), 7 bilobectomy (6.5%), 9 pneumonectomy (8.3%), and 5 exploratory thoracotomy (4.6%). The agreement between clinical staging after mediastinoscopy and pathological staging after thoracotomy was 47% (stage IA) and 57% (stage IB). CONCLUSIONS: Routine mediastinoscopy is indicated for all women with nonsmall cell lung cancer, regardless of clinical stage.

Hemotórax espontáneo por rotura de aneurisma de arteria pulmonar en la enfermedad de Rendu-Osler-Weber / Spontaneous hemothoraz due to rupture of a pulmonary artery aneurysm in Rendu-Osler-Weber syndrome

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[Octreotide for conservative management of postoperative chylothorax]. / Tratamiento conservador con octreótido del quilotórax posquirúrgico.

Postoperative chylothorax after lung resection is a major problem leading to morbidity and mortality and requiring reoperation in a large number of cases. The most advisable and least aggressive option is conservative management in progressive stages: a diet rich in medium-chain fatty acids and/or total parenteral nutrition, in addition to chest tube drainage. Including octreotide in this regimen seems to be related to a higher success rate without the need for surgery. We report a case in which the effectiveness and safety of octreotide in the resolution of postoperative chylothorax was excellent.

NasoNet, modeling the spread of nasopharyngeal cancer with networks of probabilistic events in discrete time.

The spread of cancer is a non-deterministic dynamic process. As a consequence, the design of an assistant system for the diagnosis and prognosis of the extent of a cancer should be based on a representation method that deals with both uncertainty and time. The ultimate goal is to know the stage of development of a cancer in a patient before selecting the appropriate treatment. A network of probabilistic events in discrete time (NPEDT) is a type of Bayesian network for temporal reasoning that models the causal mechanisms associated with the time evolution of a process. This paper describes NasoNet, a system that applies NPEDTs to the diagnosis and prognosis of nasopharyngeal cancer. We have made use of temporal noisy gates to model the dynamic causal interactions that take place in the domain. The methodology we describe is general enough to be applied to any other type of cancer.

Validation of a liquid chromatographic method for the determination of ranitidine hydrochloride residues on surfaces in the manufacture of pharmaceuticals.

A liquid chromatographic method for determination of the residues of ranitidine hydrochloride on various surfaces employed in drug manufacture is described. Cotton swabs, moistened with a methanol-water (1:1, v/v) mixture were used to remove any residues of drugs from glass, vinyl, and stainless steel surfaces, and gave recoveries of 85%, 78% and 90%, respectively. Residues were determined by high-performance liquid chromatography on a C18 column at 25 degrees C with methanol-ammonium acetate (40:60 v/v) pH 6.7 as the mobile phase and detection at 320 nm. The method was validated over a concentration range of 20-10 000 ng/ml and had a detection limit of 2 ng/ml.

DIAVAL, a Bayesian expert system for echocardiography.

DIAVAL is an expert system for the diagnosis of heart diseases, including several kinds of data, mainly from echocardiography. The first part of this paper is devoted to the causal probabilistic model which constitutes the knowledge base of the expert system in the form of a Bayesian network, emphasizing the importance of the OR gate. The second part deals with the process of diagnosis, which consists of computing the a posteriori probabilities, selecting the most probable and most relevant diagnoses, and generating a written report. It also describes the results of the evaluation of the program.

[IgG subclass antibodies in children of Vallidolid. Low materno-fetal protection]. / Anticuerpos antitetánicos de subclases IgG en niños de Valladolid. Escasa protección materno-fetal.

The anti-tetanus serology was studied in Valladolid during 1988. IgG-antibodies and every one of four IgG-subclasses were determined by ELISA in 144 sera. In this study were included 31 parturient women, 20 newborn, 68 children 1.5-14 years old and 25 younger than 18 months. A 0.01 UI/ml sensibiling and a 8.5% interassay variability coefficient were achieved. The highest mean antibodies level (70.9-39.6 Ua/ml) was presented by children 1.5-3 years old and the lowest (31.1 +/- 15.9 Ua/ml) by 3-5 years old; nevertheless in mothers it was only 1.0 +/- 1.6 Ua/ml. Among children 1.5-14 years old we found only 5/63 (7.9%) cases with non-protective antibodies level. On the contrary, in mothers it increased until 23/31 (74%) and until 16/20 (80%) in cord blood. Antibodies of four IgG subclasses has each other a good correlation, especially IgG1/G2/G4 (p less than 0.001). The IgG2 and IgG3 subclasses were the antibodies which lesser decreased after vaccination. We emphasize the poor anti-tetanus protection of mothers and newborns, lower than levels reported in other countries.

[Ethiology and pathology of low birth weight infants in our hospital (author's transl)]. / Correlaciones etiopatológicas del recién nacido de bajo peso, en nuestro medio

A retrospective study on 834 newborns of low birth weight, 2,500 grs., or less over a total of 19,869 live newborns during the year 1973 is presented. They are divided into low birth weight compatible with gestational age and low birth weight for gestational age when birth weight is lower than 10th percentile of Lubchenco's chart. Each of these groups is subdivided in three parts: First part refers to coincidence of frequence of different ethiologic factors or causes of low birth weight (maternal, gestational, placental and termination of pregnancy). The second part has its object in the clinical appraisal of the state at birth of these low birth weight newborns (fetal-obstetric evaluation of Velasco-Cándano, neonatal Apgar scoring, respiratory evaluation by Silvermann-Andersen and evaluation of external maturaty according to Usher). Third part of the study relates the morbility-mortality rate, need for admission, presence of congenital anomalies and autopsy findings in each of these groups of low birth weight newborns. Relation among all these estimated parameters is made presenting some conclusions reached.