Efficacy and cost-effectiveness of a blended cognitive behavioral therapy for depression in Spanish primary health care: study protocol for a randomised non-inferiority trial.

BACKGROUND: Data from primary health care in Spain show a high prevalence of the major depressive disorder. Blended treatment (combination of face-to-face and online components) seems to be a very promising tool for the optimization and dissemination of psychological treatments in a cost-effective form. Although there is growing data that confirm the advantages of blended therapies, few studies have analyzed their application in regular clinical practice. The objective of the present paper is to describe the protocol for a clinical study aimed at exploring the clinical and cost-effectiveness of a blended cognitive behavioral therapy (b-CBT) for depression, compared to treatment as usual (TAU) in a primary health care setting. METHODS: A two-arm randomised controlled non-inferiority trial will be carried out, with repeated measures (baseline, 3 months, 6 months, and 12 months) under two conditions: b-CBT and TAU. The b-CBT program will consist in three face-to-face sessions and eight online sessions. The TAU is defined as the routine care delivered by the general practitioner for the treatment of depression in primary care. The primary outcome is a symptomatic change of depressive symptoms on the patient-health questionnaire (PHQ-9). Other secondary outcomes will be considered (e.g., quality of life, treatment preference). All participants must be 18 years of age or older and meet the diagnostic criteria for major depressive disorder according to the Diagnostic and Statistical Manual of Mental disorders 4th edition. 156 participants will be recruited (78 per arm). DISCUSSION: It is expected that b-CBT is clinically non-inferior when compared to TAU. This is the first study in Spain to use a b-CBT format in primary and specialized care, and this format could be an efficacious and cost-effective therapeutic strategy for the treatment of depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT02361684. Registered on 8 January 2015. Currently recruiting participants.

Neonatal Acid-Base Status in Fetuses with Abnormal Vertebro- and Cerebro-Placental Ratios.

OBJECTIVE: A low cerebro-placental ratio (CPR) at term suggests the existence of failure to reach growth potential (FRGP) with a higher risk of poor neonatal acid-base status. This study aimed to evaluate whether similar findings were also seen in the vertebral artery (vertebro-placental ratio, VPR), supplying 30% of the cerebral flow. METHODS: We studied term fetuses classified into groups according to birth weight (BW), CPR and VPR. BW was expressed in centiles and ratios in multiples of the median (MoM). Subsequently, associations with neonatal pH values were evaluated by means of regression curves and Mann-Whitney tests. RESULTS: VPR MoM correlated with BW centiles (p < 0.0001, R2 = 0.042) and its distribution resembled that of CPR MoM (p < 0.001). When both arteries were compared, adequate-for-gestational-age (AGA) fetuses with either low CPR or low VPR had lower neonatal venous pH values (p < 0.05, p < 0.01, respectively). However, in case of small-for-gestational-age (SGA) fetuses, only those with low VPR had significantly lower neonatal arterial and venous pH values (p < 0.05). CONCLUSIONS: Blood flow in the vertebral artery mimics that in the middle cerebral artery supporting the FRGP model. Both CPR and VPR identify AGA fetuses with lower neonatal pH values, but only VPR identifies SGA with lower pH values. Hypoxemia might be reflected as a generalized cerebral vasodilation demonstrated as low CPR and VPR.

Histerectomía total laparoscópica vs. histerectomía vaginal: análisis de costes y resultados operatorios / Total laparoscopic hysterectomy vs vaginal hysterectomy. Analysis of costs and surgical outcomes

Objetivo. Analizar y comparar los resultados perioperatorios y los costes económicos de la histerectomía total laparoscópica (HTL) y de la histerectomía vaginal (HV). Sujetos y métodos. Estudio retrospectivo realizado durante 2013 que incluye pacientes con similar perfil sometidas a HV (n = 20) o HTL (n = 29). La principal indicación quirúrgica fue útero miomatoso. Se recogen datos epidemiológicos, resultados perioperatorios y datos económicos. Resultados. Las características basales de las pacientes fueron similares. En resultados perioperatorios, el tiempo quirúrgico fue menor en HV (64,8 ± 14,5 min) que en HTL (102,8 ± 20,5 min) p < 0,01. No se encontraron diferencias significativas en peso uterino, caída de la hemoglobina y estancia hospitalaria. El coste medio de la HTL (2.036 ± 307 euros) fue significativamente mayor al de la HV (1.604 ± 346 euros). Conclusiones. En la elección de la vía quirúrgica, la HV parece ser un procedimiento más económico y con similares resultados perioperatorios que la HTL. No obstante, es importante individualizar según las características de la paciente. Son necesarios estudios con mayor tamaño muestral para confirmar los resultados (AU)

Objective. To evaluate and compare surgical outcomes and the overall costs of total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH). Subjects and methods. A retrospective study was conducted that compared surgical outcomes and hospital costs obtained during 2013 in patients with similar profiles undergoing VH (n = 20) or TLH (n = 29). Epidemiological data, perioperative results and economic data were compared between the two groups. Results. Baseline characteristics were similar between the two groups. The mean operating time was shorter in the VH group (64.8 ± 14.5 min) than in the TLH group (102.8 ± 20.5 min) p < 0.01. No differences were found between the two groups in uterine weight, decrease in hemoglobin or length of hospital stay. The mean cost was significantly higher for TLH (Euros 2036 ± 307) than for VH (Euros 1603 ± 346). Conclusions. Our data suggest that VH is less expensive than TLH and has similar perioperative outcomes. Nevertheless, the choice of surgical route should be based on the patient's characteristics. Further studies with larger samples are required to confirm our data (AU)

Embarazo ectópico sobre cicatriz de cesárea / Ectopic caesarean scar pregnancy

El embarazo ectópico sobre cicatriz de cesárea previa ha aumentado su incidencia en los últimos años, debido probablemente al aumento en el número de cesáreas realizadas. Su importancia se debe a las potenciales graves consecuencias que pueden surgir en caso de progreso del embarazo. El anidamiento embrionario en esta zona se ha explicado aludiendo a que la liberación de diferentes factores, como citocinas, y la expresión de distintos receptores de superficie facilitarían la adhesión embrionaria, favorecida en las cicatrices de cirugías endometriales por su gran atracción quimiotáctica secundaria al proceso inflamatorio y de reparación tisular que allí se produce. Su manejo resulta controvertido por el escaso número de casos publicados, lo que hace difícil establecer un protocolo de actuación. Se han descrito varios tipos de tratamiento, tanto quirúrgicos como farmacológicos, con buenos resultados. Presentamos un caso en el que fue diagnosticada ecográficamente una gestación ectópica sobre cicatriz de cesárea, resuelta con tratamiento farmacológico con metotrexate. En este caso, se evidencia la importancia del seguimiento, tanto clínico como ecográfico y del nivel de beta-HCG, hasta su resolución completa (AU)

Ectopic caesarean scar pregnancy has increased in incidence in recent years, probably as a result of the rise in the number of caesarean sections performed. Its importance is due to the potentially serious consequences that can arise if the pregnancy progresses. It has been suggested that the embryonic nesting in this area may be due to the release of factors such as cytokines, and the expression of different surface receptors. These factors would facilitate the embryonic adherence, favoured in endometrial surgery scars for their great chemotactic attraction, which is secondary to the inflammatory process and tissue repair that occurs there. Its management remains controversial as the low number of reported cases makes it difficult to establish a protocol. Several types of treatment, surgical as well as pharmacological, have been described with good results. We report a case of caesarean scar pregnancy diagnosed on ultrasound, and resolved with conservative treatment with methotrexate. In this case, it demonstrates the importance of monitoring the clinical condition, as well as using ultrasound and beta-HCG levels until its full resolution (AU)

Linfangioleiomiomatosis pulmonar y gestación / Pulmonary lymphangioleiomyomatosis and pregnancy

La linfangioleiomiomatosis (LAM) es una rara enfermedad pulmonar intersticial de muy baja incidencia, que ocasiona complicaciones importantes durante la gestación por mala adaptación a los cambios cardiorrespiratorios propios del embarazo. Presentamos el caso de una paciente diagnosticada de LAM en la infancia, que presentó 2 cuadros de disnea con buena resolución y evolución de su gestación(AU)

Lymphangioleiomyomatosis (LAM) is a rare interstitial lung disease with a very low incidence, which causes serious complications during pregnancy due to poor cardiorespiratory adaptation to the changes produced by pregnancy. We report a patient diagnosed with LAM in childhood, who experienced two episodes of dyspnea with good resolution and pregnancy outcome(AU)

Ultrasound evaluation of congenital cervical teratoma and therapeutic management (ex utero intrapartum treatment).

The ultrasound evaluation of the fetal neck has a high importance as a key point of the airway and digestive tract. We report the case of a fetus diagnosed with a cervical teratoma by ultrasound, which generated a compressive effect on airway, requiring a surgical approach EXIT (ex utero intrapartum treatment) to ensure the extrauterine viability.