Análisis de coste-efectividad de la terapia de resincronización cardíaca en pacientes con insuficiencia cardíaca grave / Custo-efetividade da terapia de ressincronização cardíaca em pacientes com insuficiência cardíaca grave / Cost-effectiveness of cardiac resynchronization therapy in patients with severe heart failure

Introducción. La terapia de resincronización cardíaca es un tratamiento eficaz para el tratamiento de la insuficiencia cardíaca, que reduce la mortalidad y el número de hospitalizaciones, y mejora la calidad de vida. Material y métodos. Se evalúa la eficiencia de la resincronización cardíaca comparada con el mejor tratamiento farmacológico mediante una evaluación económica adaptada a nuestro entorno sanitario. Se realizan varios modelos económicos de Markov. Se usa la perspectiva del sistema sanitario; el horizonte temporal es la duración prevista del dispositivo, estimada en 7 años. Se incluyen parámetros derivados de ensayos clínicos y estudios observacionales, tanto de pacientes ambulatorios como hospitalizados, y de un meta-análisis. Los participantes son pacientes con insuficiencia cardíaca sintomática en estadios funcionales III-IV según New York Heart Association, con QRS ancho, depresión grave de la función sistólica y ritmo sinusal. Se compara la resincronización cardíaca añadida al mejor tratamiento médico, frente a ese tratamiento médico óptimo. Las variables de resultado fueron años de vida y años de vida ajustados por calidad. Resultados. La resincronización cardíaca, añadida al mejor tratamiento médico, es un tratamiento coste-efectivo, con valores de ratio coste-efectividad de € 6.627 - 8.739 por año de vida ajustado a calidad de vida. Conclusiones. La resincronización cardíaca es un tratamiento eficiente, o coste-efectiva, para estos pacientes seleccionados. Este resultado varía poco al modificar las variables incluidas en el modelo. La inclusión de dispositivos con funcionalidad desfibrilador automático implantable no se ha incluido en nuestro trabajo, pero su valor probablemente sea mucho mayor.

Introduction. The therapy of cardiac resynchronization is effective for the treatment of the heart failure, which reduces mortality and number of hospitalizations, and improves quality of life. Material and methods. We evaluate the efficiency of the cardiac resynchronization compared with the best pharmacological therapy by means of an economic evaluation adapted to our sanitary environment. We developed several economic models of Markov. The perspective of the sanitary system is used; the temporary horizon is the duration foreseen of the device, estimated in 7 years. There are included parameters derived from clinical trials and observational studies, with ambulatory and hospitalized patients, and from a meta-analysis. They are patients with symptomatic heart failure with functional class NYHA III-IV, with wide QRS, severe depression of systolic function and sinusal rhythm. We compare cardiac resynchronization added to the best medical treatment, opposite to this medical treatment. Measured variables are years of life and years of life adjusted by quality. Results. The cardiac resynchronization added to the best medical treatment, is a cost- effective treatment, with values of incremental cost - effectiveness of € 6,627 - 8,739 for year of life adjusted to quality of life. Conclusions. The cardiac resynchronization is a cost-effective treatment for these patients. This result changes little on having modified the variables included in the model. The incorporation of devices with implantable cardioverter defibrillator functionality has not been included in our work, but his value probably is greater.

Introdução. A terapia de ressincronização cardíaca é um tratamento eficaz para a insuficiência cardíaca, que reduz a mortalidade e hospitalizações, e melhora a qualidade de vida. Material e métodos. É avaliada a eficiência da terapia de ressincronização cardíaca em comparação com o melhor tratamento de drogas através de uma avaliação econômica adaptada ao nosso ambiente de saúde. Vários modelos econômicos de Markov são realizados. A perspectiva do sistema de saúde é usada; o horizonte de tempo é o tempo de vida do dispositivo, estimada em 7 anos. Parâmetros derivados de ensaios clínicos e estudos observacionais, tanto ambulatoriais e internações, e uma meta-análise está incluída. Os participantes são pacientes com insuficiência cardíaca sintomática com NYHA III- IV, com QRS largo, depressão grave da função sistólica e do ritmo sinusal estágios funcionais. Ressincronização cardíaca adicionada a melhor terapia médica é comparado com o tratamento clínico otimizado. As variáveis respostas foram anos de vida e anos de vida ajustados pela qualidade. Resultados. Terapia de ressincronização cardíaca, somada à melhor terapia médica, é um tratamento de baixo custo com valores de relação custo- eficácia dos € 6627-8739 por ano de vida ajustado por qualidade de vida. Conclusões. Terapia de ressincronização cardíaca é um tratamento de baixo custo para esses pacientes selecionados. Esse resultado varia pouco alterando as variáveis incluídas no modelo. A inclusão de dispositivos com funcionalidades cardioversor desfibrilador implantável não foi incluído em nosso trabalho, mas o seu valor é, provavelmente, muito maior.

[Usefulness of phyto-oestrogens in reduction of blood pressure. Systematic review and meta-analysis]. / Utilidad de los fitoestrógenos en la reducción de la presión arterial. Revisión sistemática y metaanálisis.

OBJECTIVES: To determine whether treatment with phyto-oestrogens or soya protein succeeds in lowering blood pressure. DESIGN: A systematic review, evaluating all the observation studies and clinical trials, was conducted, followed by a meta-analysis to evaluate blood pressure variations in patients treated with phyto-oestrogens. SEARCH: The search strategy adopted used the terms "phyto-oestrogens," "soya meals," "hypertension," and "blood pressure." DATA SOURCES: The data bases MEDLINE, EMBASE, Cochrane, OVID were used, without time or language restrictions. References in the relevant articles were searched for manually. STUDY SELECTION: Two independent reviewers analysed the studies found in the search. DATA EXTRACTION: The Jadad scale was used for the clinical trials and the numerical data in the text or referred to in tables were extracted. Evaluation was made of which observational and experimental articles showed a drop in blood pressure with phyto-oestrogens and which did not. In the meta-analysis, data on sample size, difference in blood pressure before and after intervention and standard deviation were extracted from each study. The weighted difference of means was used with the model of randomised effects. The Review Manager v4.2.9 programme was used. RESULTS: No significant variations in blood pressure were found, whether systolic (-1.20 mm Hg; 95% CI, -2.80 to 0.41 mm Hg) or diastolic (-1.31 mm Hg; 95% CI, -2.73 to 0.11). If there were any variations, they are clinically of little importance. There was also an important degree of both statistical and clinical heterogeneity. CONCLUSIONS: There are no statistically significant or clinically important differences in blood pressure between patients treated with phyto-oestrogens and those not treated.

Utilidad de los fitoestrógenos en la reducción de la presión arterial. Revisión sistemática y metaanálisis / Usefulness of phyto-oestrogens in reduction of blood pressure. Systematic review and meta-analysis

Objetivos. Determinar si el tratamiento con fitoestrógenos o proteína de soja logra descensos de la presión arterial. Diseño. Se realizó una revisión sistemática, valorando todos los estudios observacionales y ensayos clínicos, y un metaanálisis para evaluar la variación de la presión arterial en pacientes tratados con fitoestrógenos. Búsqueda. Se usó una estrategia de búsqueda con los términos «fitoestrógenos» o «comidas de soja» e «hipertensión» o «tensión arterial». Fuentes de datos. Se utilizaron las bases de datos MEDLINE, EMBASE, Cochrane Database y OVID sin restricción temporal ni de idioma. Se realizó una búsqueda manual de las referencias de los artículos de interés. Selección de estudios. Dos evaluadores independientes analizaron los trabajos obtenidos en la búsqueda. Extracción de datos. Se aplicó la escala de Jadad a los ensayos clínicos, y se extrajeron los datos numéricos del texto o referidos en tablas. Se valoró qué artículos observacionales y experimentales mostraban descenso de la presión arterial con fitoestrógenos y cuáles no. Se realizó el metaanálisis, extrayendo de cada estudio datos de tamaño muestral, diferencia de presión arterial tras la intervención y basalmente y desviación estándar. Se usó la diferencia ponderada de medias con el modelo de efectos aleatorios. Se utilizó el programa Review Manager v4.2.9. Resultados. No se observaron variaciones significativas de la presión arterial, tanto sistólica (­1,20 mmHg; intervalo de confianza [IC] del 95%, ­2,80 a 0,41 mmHg) como diastólica (­1,31 mmHg; IC del 95%, ­2,73 a 0,11); si las hay, estas variaciones parecen clínicamente poco importantes. También hay un grado importante de heterogeneidad, tanto estadística como clínica. Conclusiones. No hay diferencias estadísticamente significativas ni clínicamente importantes de presión arterial en tratados con fitoestrógenos frente a no tratados

Objectives. To determine whether treatment with phyto-oestrogens or soya protein succeeds in lowering blood pressure. Design. A systematic review, evaluating all the observation studies and clinical trials, was conducted, followed by a meta-analysis to evaluate blood pressure variations in patients treated with phyto-oestrogens. Search. The search strategy adopted used the terms "phyto-oestrogens," "soya meals," "hypertension," and "blood pressure." Data sources. The data bases MEDLINE, EMBASE, Cochrane, OVID were used, without time or language restrictions. References in the relevant articles were searched for manually. Study selection. Two independent reviewers analysed the studies found in the search. Data extraction. The Jadad scale was used for the clinical trials and the numerical data in the text or referred to in tables were extracted. Evaluation was made of which observational and experimental articles showed a drop in blood pressure with phyto-oestrogens and which did not. In the meta-analysis, data on sample size, difference in blood pressure before and after intervention and standard deviation were extracted from each study. The weighted difference of means was used with the model of randomised effects. The Review Manager v4.2.9 programme was used. Results. No significant variations in blood pressure were found, whether systolic (­1.20 mm Hg; 95% CI, ­2.80 to 0.41 mm Hg) or diastolic (­1.31 mm Hg; 95% CI, ­2.73 to 0.11). If there were any variations, they are clinically of little importance. There was also an important degree of both statistical and clinical heterogeneity. Conclusions. There are no statistically significant or clinically important differences in blood pressure between patients treated with phyto-oestrogens and those not treated

[GUTI-VAL apparatus: respiratory deficiency and non-invasive ventilation]. / Dispositivo GUTI-VAL. Insuficiencia respiratoria con ventilación no invasiva.

Mechanical non-invasive ventilation provides a useful therapeutic option to treat some types of respiratory deficiencies. This apparatus improves the morbid mortality rate and shortens hospital stays especially since it prevents tracheotomy, but it can produce some inconveniences. The authors evaluate the efficiency of the GUTI-VAL Connection Apparatus in the treatment of patients suffering from a respiratory deficiency used along with a CPAP mask in terms of the degree of comfort and acceptance patients have, the prevention of a tracheotomy and of cutaneous lesions. This study, run over a 13 month period, dealt with patients checked into our Intensive Care Unit, a multidimensional unit in a county hospital, suffering from acute respiratory deficiencies or chronic acute deficiencies to whom treatment with mechanical non-invasive ventilation type CPAP with a GUTI-VAL apparatus was applied. The authors conclude that this apparatus proved to have a low mortality rate, few complications and good patient tolerance.

Dispositivo GUTI-VAL. Insuficiencia respiratoria con ventilación no invasiva / GUTI-VAL apparatus: respiratory deficiency and non-invasive ventilation

La ventilación mecánica no invasiva (VMNI) supone una opción terapéutica útil en el tratamiento de ciertos tipos de insuficiencia respiratoria. Mejora las tasas de morbi-mortalidad y acorta la estancia hospitalaria, sobre todo al evitar la intubación, pero puede producir inconvenientes. Se evalúa la eficacia del dispositivo de sujeción GUTI-VAL en el tratamiento de la insuficiencia respiratoria con la mascarilla CPAP en términos de comodidad y aceptación del paciente, prevención de la intubación de lesiones cutáneas. Se trata de pacientes ingresados a lo largo de 13 meses en nuestra UCI, unidad polivalente de un hospital comarcal, por insuficiencia respiratoria aguda o crónica agudizada, a los que se trató con VMNI modo CPAP con el dispositivo GUTI-VAL. Se concluye que dicho dispositivo se asocia a baja morbilidad, escasas complicaciones y buena tolerancia

Mechanical non-invasive ventilation provides a useful therapeutic option to treat some types of respiratory deficiencies. This apparatus improves the morbid mortality rate and shortens hospital stays especially since it prevents tracheotomy, but it can produce some inconveniences. The authors evaluate the efficiency of the GUTI-VAL Connection Apparatus in the treatment of patients suffering from a respiratory deficiency used along with a CPAP mask in terms of the degree of comfort and acceptance patients have, the prevention of a tracheotomy and of cutaneous lesions. This study, run over a 13 month period, dealt with patients checked into our Intensive Care Unit, a multidimensional unit in a county hospital, suffering from acute respiratory deficiencies or chronic acute deficiencies to whom treatment with mechanical non-invasive ventilation type CPAP with a GUTI-VAL apparatus was applied. The authors conclude that this apparatus proved to have a low mortality rate, few complications and good patient tolerance