Cost-effectiveness of myocardial perfusion SPECT and stress test according to coronary revascularization therapy, cardiac events and total mortality: Register of 8,496 patients. / Coste-efectividad de la SPECT de perfusión miocárdica y de la prueba de esfuerzo en relación con la revascularización coronaria, eventos cardíacos y mortalidad total. Registro de 8.496 pacientes.

OBJECTIVE: The aim was to analyze the cost-effectiveness ratio (CER) of stress electrocardiogram (ES) and stress myocardial perfusion imaging (SPECT-MPI) according to coronary revascularization (CR) therapy, cardiac events (CE) and total mortality (TM). MATERIAL AND METHODS: A total of 8,496 consecutive patients who underwent SPECT-MPI were followed-up (mean 5.3±3.5years). Cost-effectiveness for coronary bypass (CABG) or percutaneous CR (PCR) (45.6%/54.4%) according to combined electrocardiographic ischemia and scintigraphic ischemia were evaluated. Effectiveness was evaluated as TM, CE, life-year saved observed (LYSO) and CE-LYSO; costs analyses were conducted from the perspective of the health care payer. A sensitivity analysis was performed considering current CABG/PCR ratios (12%/88%). RESULTS: When electrocardiogram and SPECT approaches are combined, the cost-effectiveness values for CABG ranged between 112,589€ (electrocardiographic and scintigraphic ischemia) and 2,814,715€ (without ischemia)/event avoided, 38,664 and 2,221,559€/LYSO; for PCR ranged between 18,824€ (electrocardiographic and scintigraphic ischemia) and 46,377€ (without ischemia)/event avoided, 6,464 and 36,604€/LYSO. To CE: the cost-effectiveness values of the CABG and CPR in presence of electrocardiographic and scintigraphic ischemia were 269,904€/CE-avoided and 24,428€/CE-avoided, respectively; and the €/LYSO of the CABG and PCR were 152,488 and 13,801, respectively. The RCE was maintained for the current proportion of revascularized patients (12%/88%). CONCLUSIONS: Combined ES and SPECT-MPI results, allows differentiation between patient groups, where the PCR and CABG are more cost-effective in different economic frameworks. The major CER in relation to CR, CE and TM occurs in patients with electrocardiographic and scintigraphic ischemia. PCR is more cost-effective than CABG.

Forum for debate: Safety of allogeneic blood transfusion alternatives in the surgical/critically ill patient.

In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues.

Intravenous immunoglobulin preparations and autoimmune disorders: mechanisms of action.

Intravenous immunoglobulins (IVIg) have been used as a substitutive treatment for primary and secondary humoral immune deficiencies for several decades. In the meantime, increased experience has been acquired with IVIg in the management of other inflammatory and autoimmune disorders, such as Kawasaki's disease, idiopathic thrombocytopenic purpura, dermatomyositis or Guillain-Barré syndrome, in which several clinical trials have demonstrated its efficacy. In other pathologies, IVIg seem to be effective, although further studies are required. Nevertheless, the exact mechanism by which IVIg exert their beneficial actions is not completely understood. According to in vitro as well as in vivo data, several mechanisms of action have been proposed: Fc receptor blockade, idiotype-anti-idiotype interactions, neutralisation of bacterial toxins and superantigens, competitive inhibition of complement activation, down-regulation of B- and T-cell function, enhancement of pathogenic autoantibodies clearance, modulation of soluble products, apoptosis blockade via Fas receptor and administration of soluble products which could interfere with the immune response. Both IVIg structure, as well as its obtention from pooled human plasma donors, seem to play an important role in IVIg immunomodulatory properties. Thus, the objective of the present article is to review the current evidence upon the mechanisms of action of IVIg.

[Assesing the GRDOSIS Software program as a tool to analyse drug usase by DRGs]. / Evaluación del programa informático GRDOSIS como herramienta de análisis de la utilización de medicamentos por GRD.

OBJECTIVE: To validate the GRDOSIS software program as a tool to calculate Spanish drug weights within diagnosis-related groups (DRGs), and to analyse information used in this calculation. MATERIAL AND METHODS: Information corresponding to a 7-hospital sample is analysed after exchanging data between the minimum basic data set processed by the DRG-grouping program Estación Clínica -3M and unit-dose drug consumption. Data are purged by eliminating cases with an unusual (either long or short) length of stay in each DRG, and both weights and pondered weights are calculated. Data from the 5 most prevalent DRGs are analysed by using the different options provided by the software program, with the aim of detecting intervention points in order to improve results. RESULTS: Extreme case elimination noticeably reduces mean cost per DRG. A reduced group of DRGs represents a high percentage of total cost. Similarly, a reduced number of drugs may represent a high percentage of cost within a given DRG. The use of specific therapeutic groups for specific DRGs is demonstrated, as is the correct use of first-choice drugs versus other therapeutic options within therapeutic groups. An unwarranted variability regarding drug administration dosing and frequency is, however, observed. CONCLUSIONS: The GRDOSIS software program proves itself a powerful tool for both the qualitative (drug usage profiles, dosage) and quantitative (costs) analysis of information originating in a Pharmacy Department

Tratamiento de la hipertensión esencial / The arterial hipertension treatment

Se revisa la hipertensión arterial (HTA) y su tratamiento. Inicialmente se definen el concepto de HTA y los factores de riesgo que condicionan su tratamiento. A continuación se describen las medidas no farmacológicas para el tratamiento de la HTA. Posteriormente se revisan los hipotensores clásicos junto con las últimas novedades terapéuticas (antagonistas de los receptores de angiotensina II). Se plantea el algoritmo del tratamiento establecido por The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI), y cuáles son los fármacos que deben escogerse en presencia de enfermedades concomitantes. Por último se repasa el tratamiento de las urgencias y emergencias hipertensivas (AU)

Glutathione and cysteine in HIV-infected hemophiliacs.

A cross-sectional study was designed to determine whether plasma concentrations of glutathione and cysteine in HIV-infected hemophiliacs vary according to the progression of the disease and to compare them with those obtained in HIV negative hemophiliacs. Cysteine, total glutathione and glutathione disulphide were measured in plasma of HIV-infected hemophiliacs at different stages of HIV infection and in plasma of HIV-negative hemophiliacs. CD4 and CD8 T-cell counts, leukocyte and lymphocyte counts, beta 2-microglobulin and p24 antigen values were recorded for HIV positive hemophiliacs at the time of the study. The hemophiliac HIV-positive group showed a decrease in total glutathione levels (-18%) and an increase of glutathione disulphide (8.18 vs. 14.90%) compared to the HIV-negative group. The cysteine levels found in HIV-positive hemophiliacs were not different from those found in the HIV-negative group. There were no differences with statistical significance in total glutathione, glutathione disulphide and cysteine among HIV-infected hemophiliacs according to the different clinical stage of the disease (AIDS vs. non-AIDS). The interest of evaluating plasma concentrations of glutathione and cysteine in HIV-infected patients is limited from the point of view of considering them as markers of progression of the disease. Interest in a therapeutic strategy designed to replenish or normalize glutathione plasma levels is also limited.

[Progression of HIV infection in a cohort of hemophiliacs over an 11-year period]. / Progresión de la infección por el virus de la inmunodeficiencia humana en una cohorte de hemofílicos durante un período de 11 años.

BACKGROUND: The progression of HIV infection in a cohort of hemophiliacs was evaluated taking into consideration the particularities of the natural history of HIV in this population and comparing the same with that described for other series of hemophiliacs and other risk groups for HIV infection. METHODS: A cohort of 141 hemophiliac patients with HIV infection controlled in a Hemophilia Unit since January 1983 was studied. The accumulated incidence of AIDS and the mortality at 11 years of follow up were evaluated. Likewise, the association of prognostic factors such as age, type of hemophilia or previous treatment with antihemophilic factors were evaluated. RESULTS: The accumulated incidence of AIDS at the end of follow up was 56% with a mortality rate of 33%. The evolution showed statistically significant differences with regard to age (p = 0.00048) and previous treatment (p = 0.00239). No differences were observed concerning the type of hemophilia or its severity. CONCLUSIONS: HIV infection in the cohort of hemophiliacs studied presented similar accumulated AIDS incidence and mortality to those described in other series of hemophiliacs. These values are apparently more favorable than those referred for other risk groups, possibly due to the particular epidemiologic characteristics.

[The effect of the type of factor VIII concentrate on the CD4 lymphocyte count in hemophiliacs with human immunodeficiency virus infection: the results of a meta-analysis]. / Influencia del tipo de concentrado de factor VIII sobre la cifra de linfocitos CD4 en hemofílicos con infección por el virus de la inmunodeficiencia humana: resultado de un metaanálisis.

BACKGROUND: The administration of factor VIII concentrates of intermediate purity in HIV+ hemophiliac patients has been related with disorders of the immunologic system of these patients which may be observed in a more acute decrease in CD4 lymphocyte count in relation to that described in patients treated with products of greater purity. The present study evaluates the impact of these treatments (concentrates of intermediate or high purity) on the immune system of HIV+ hemophiliac patients by exhaustive analysis of the literature. METHODS: Meta-analysis of 8 clinical studies published between 1983 and 1993 was performed by multivariate analysis which considers the decrease in the number of CD4 lymphocytes as an indicator of the evolution of the disease. Likewise, the size of the effect and combined significance were also evaluated. RESULTS: The absolute decrease in the number of CD4 lymphocytes is significantly lower in patients treated with products of greater purity (354 +/- 52 vs 448 +/- 54 cells/microliters p = 0.037) as was the size of the effect and the different tests of combined significance. The speed of decrease was between 1.25 and 16.55 cells/microliters/year lower in the treated group than in the control (p = 0.029). CONCLUSIONS: According to meta-analysis, the factor VIII concentrates of intermediate purity influence the immune system of HIV+ hemophiliac patients to a greater extent leading to a more acute decrease in the number of CD4 lymphocytes over time. Further studies are required to confirm whether this facts leads to differences in clinical manifestations of the infection or in survival.

[The administration of factor VIII concentrates to hemophiliacs by continuous perfusion pump]. / Administración de concentrados de factor VIII a hemofílicos mediante bomba de perfusión continua.

BACKGROUND: The administration of factor VIII (FVIII) in continuous infusion (CI) to hemophiliac inpatients is a therapeutic approach made possible by the development of new commercial preparations. METHODS: In the present study the outcome of 14 treatment courses of FVIII in CI to 12 patients with hemophilia A (2 of them with inhibitor) was evaluated. A computer program developed by the authors is presented. This program is simple and can be executed in any compatible personal computer, permitting the calculation of initial and maintenance doses and individual pharmacokinetic parameters. RESULTS: The hemostatic result was excellent: constant FVIII plasma levels were achieved, and unnecessary overdoses were prevented. Mean infusion rates of 1.99 +/- 0.45 IU/kg/h, 1.47 +/- 0.28 IU/kg/h, and 0.86 +/- 0.12 IU/kg/h were enough to maintain FVIII plasma levels of 1 IU/ml, 0.3 IU/ml, and 0.3 IU/ml, respectively. This represents a saving of 20-50% of the requirements of the traditional intermittent method. CONCLUSIONS: The infusion of intravenous CI of FVIII and the use of a computer program permitting an easy individualization of the treatment schedule resulted in the same hemostatic effectiveness as with the traditional intermittent method, but using a smaller replacement dose.