Challenges of Health Technology Assessment in Pluralistic Healthcare Systems: An ISPOR Council Report.

Health technology assessment (HTA) has been growing in use over the past 40 years, especially in its impact on decisions regarding the reimbursement, adoption, and use of new drugs, devices, and procedures. In countries or jurisdictions with "pluralistic" healthcare systems, there are multiple payers or sectors, each of which could potentially benefit from HTA. Nevertheless, a single HTA, conducted centrally, may not meet the needs of these different actors, who may have different budgets, current standards of care, populations to serve, or decision-making processes. This article reports on the research conducted by an ISPOR Health Technology Assessment Council Working Group established to examine the specific challenges of conducting and using HTA in countries with pluralistic healthcare systems. The Group used its own knowledge and expertise, supplemented by a narrative literature review and survey of US payers, to identify existing challenges and any initiatives taken to address them. We recommend that countries with pluralistic healthcare systems establish a national focus for HTA, develop a uniform set of HTA methods guidelines, ensure that HTAs are produced in a timely fashion, facilitate the use of HTA in the local setting, and develop a framework to encourage transparency in HTA. These efforts can be enhanced by the development of good practice guidance from ISPOR or similar groups and increased training to facilitate local use of HTA.

EQ-5D-5L Health-State Values for the Mexican Population.

OBJECTIVE: To generate a value set for the Mexican adult general population to support and facilitate the inclusion of quality-adjusted life years (QALYs) into the health technology assessment process of the Mexican healthcare authorities. METHODS: A representative sample of the Mexican adult population stratified by age, sex and socio-economic status was used. Following version 2.0 of the EuroQol EQ-5D-5L valuation protocol, trained interviewers guided participants in completing composite time trade-off (cTTO) and discrete-choice experiment (DCE) tasks included in the EQ-VT software. Generalized least squares, Tobit and Bayesian models were used for cTTO data. The choice of value set model was based on criteria that included: theoretical considerations, parsimony, logical ordering of coefficients, and statistical significance. RESULTS: Based on quality control criteria and interviewer judgment, 1000 out of 1032 participants provided useable responses. Participants' demographic characteristics were similar to the 2010 Mexican Population Census and followed the socioeconomic structure defined by the Mexican Association of Marketing Research and Public Opinion Agencies (AMAI). The predicted index values in the final cTTO model (a heteroscedastic censored model with Bayesian estimation) ranged from - 0.5960 to 1, with 19.7% of all predicted health state scores less than 0 (i.e., worse than dead). CONCLUSION: This study has generated the first value set representing the stated preferences of the Mexican adult population for use in estimating QALYs. The resulting EQ-5D-5L value set is technically robust and will facilitate health economic analyses as well as quality-of-life studies.

Comparison of the effect of whole-body vibration therapy versus conventional therapy on functional balance of patients with Parkinson's disease: adding a mixed group.

OBJECTIVE: Assess the effect of Whole-Body Vibration (WBV) therapy in functional balance status of Parkinson's disease (PD) patients and compare this to conventional and combined therapy. INTRODUCTION: PD patients experience a decreased mobility, inactivity, and loss of independence as consequence of disturbances in gait, posture, and balance. Rehabilitation therapy is a non-pharmacological way of improving functionality. One of the most studied modalities is WBV, with multiple studies showing improvement in motor function. However, results in this manner are inconsistent. METHODS: Forty-five patients were enrolled in a non-randomized controlled trial and divided into three groups. Group 1 received conventional therapy (thermotherapy, stretching, strengthening, coordination and balance). Group 2 received WBV therapy, and group 3 patients underwent a combined therapy protocol. A total of 20 sessions (3 per week) were conducted, assessing Berg Balance Scale (BBS) before initial and after final session. RESULTS: The 3 intervention groups showed significant improvement in BBS scores after concluding the 20-session trial compared to initial assessment. When comparing mean change in BBS score from initial to final assessment, the combined therapy group had a greater increase compared to conventional therapy, but no significant differences were observed comparing to WBV group. Mean change in BBS score showed no significant difference between conventional therapy and WBV therapy group. CONCLUSIONS: WBV therapy is a useful tool as co-adjuvant in conventional therapy. The combination of both therapies is a significant therapeutic alternative for the improvement of functional balance status in PD patients compared to conventional therapy alone.

Relationship between left ventricular hypertrophy and somatotype of high performance athletes using structural equations modeling / Relación entre la hipertrofia ventricular izquierda y el somatotipo en atletas de alto rendimiento utilizando modelamiento de ecuaciones estructurales

Introduction: Sports induce morphological and functional adaptations in the human heart that directly relate to the type, duration and intensity of training and the years of practice. These changes are present in different ways in the electrocardiogram. A high QRS voltage is the most significant finding. Its correlation with left ventricular hypertrophy is low. In this study, the aim was to determine if a relationship exists between electrocardiographic alterations of left ventricular hypertrophy and somatotype in high performance athletes. Methods: A retrospective, cross-sectional, quantitative, multiple correlation, observational and analytical study of a database of 180 resting electrocardiograms and anthropometric evaluations of men's soccer, women's soccer, swimming, cycling, basketball, and tennis athletes was performed. A database containing somatotype and Sokolow-Lyon electrocardiographic voltage criteria was created. Results: The study group was composed of 83.3% men and 16.7% women. Age ranged from 10 to 51 years with a mean of 19.73 ± 5.8. Weight ranged from 35.90 to 122.3 kg with a mean of 66.98 ± 12.67 and height ranged from 143 to 213 cm with a mean of 174.11 ± 10.29 cm. Endomorphy for the entire group ranged from 1.0 to 5.7 with a mean of 2.5 ± 0.9. Mesomorphy ranged from 1.6 to 7.1 with a mean of 4.2 ± 0.95. Ectomorphy ranged from 1.1 to 5.8 with a mean of 2.9 ± 0.96. The structural equation model had a normal multivariable distribution of 3.161, reaching a Pearson of .26 for mesomorphy with a goodness of fit and a variance of 0% for mesomorphy and left ventricular hypertrophy. Conclusion: Based on the findings, we can say that somatotype does not predict left ventricular hypertrophy in high per-formance athletes

Introducción: Los deportes inducen adaptaciones morfológicas y funcionales en el corazón humano directamente relacionadas con el tipo, duración e intensidad del entrenamiento y los años de práctica. Estos cambios se manifiestan de diversas formas en el electrocardiograma. Un alto voltaje del QRS es el hallazgo más significativo. Su correlación con la hipertrofia ventricular izquierda es baja. En este estudio, el objetivo era determinar si existe una relación entre las alteraciones electrocardiográficas de hipertrofia ventricular izquierda y el somatotipo en deportistas de alto rendimiento. Métodos: Se efectuó un estudio transversal, cuantitativo, observacional, analítico retrospectivo de correlación múltiple de una base de datos de 180 electrocardiogramas en reposo y antropometría de atletas de soccer varonil, soccer femenil, natación, basquetbol, ciclismo y tenis. Se creó una base de datos con el somatotipo y los criterios de voltaje electrocardiográfico de Sokolow-Lyon. Resultados: El grupo de estudio estaba compuesto por 83,3% varones y 16,7% mujeres. El rango de edad fue de 10 a 51 años con una media de 19,73 ± 5,8. El peso varió de 35,90 a 122,3 kg con una media de 66,98 ± 12,67 y la estatura varió de 143 a 213 cm con una media de 174,11 ± 10,29 cm. Endomorfia para todo el grupo osciló entre 1,0 y 5,7 con una media de 2,55 ± 0,9. Mesomorfia varió de 1,6 a 7,1 con una media de 4,2 ± 0,95. Ectomorfia varió de 1,1 a 5,8 con una media de 2,9 ± 0,96. El modelo de ecuaciones estructurales tenía una distribución multivariable normal de 3.161, alcanzando un Pearson de 0,26 para mesomorfia con una bondad de ajuste y una varianza de 0% para mesomorfia e hipertrofia ventricular izquierda. Conclusiones: En base a los hallazgos podemos decir que el somatotipo no predice hipertrofia ventricular izquierda en atletas de alto rendimiento

Targeting DNA with small molecules: a comparative study of a library of azonia aromatic chromophores.

A library of azonia aromatic cations has been studied in order to gain insights into the effect of the size, shape and charge distribution on the fluorescence, DNA interactions and DNA sequence selectivity properties. Fluorescence-based thermal denaturation experiments, spectrofluorimetric titrations, circular dichroism measurements and theoretical simulations have shown that some of the studied chromophores have interesting fluorescence properties and two of them also show a consistent DNA-binding ability by intercalation, with a potential preference for AT-rich sequences.

[Cost-effectiveness analysis of etanercept compared with other biologic therapies in the treatment of rheumatoid arthritis]. / Etanercept y otras terapias biológicas en artritis reumatoide. Un análisis de costo-efectividad.

OBJECTIVE: to conduct cost-effectiveness analysis of etanercept compared with other biologic therapies in the treatment of moderate or severe rheumatoid arthritis in patients with previous unresponse to immune selective anti-inflammatory derivatives failure. METHODS: a pharmacoeconomic model based on decision analysis to assess the clinical outcome after giving etanercept, infliximab, adalimumab or tocilizumab to treat moderate or severe rheumatoid arthritis was employed. Effectiveness of medications was assessed with improvement rates of 20 % or 70 % of the parameters established by the American College of Rheumatology (ACR 20 and ACR 70). RESULTS: the model showed that etanercept had the most effective therapeutic response rate: 79.7 % for ACR 20 and 31.4 % for ACR 70, compared with the response to other treatments. Also, etanercept had the lowest cost ($149,629.10 per patient) and had the most cost-effective average ($187,740.40 for clinical success for ACR 20 and $476,525.80 for clinical success for ACR 70) than the other biologic therapies. CONCLUSIONS: we demonstrated that treatment with etanercept is more effective and less expensive compared to the other drugs, thus making it more efficient therapeutic option both in terms of means and incremental cost-effectiveness ratios for the treatment of rheumatoid arthritis.

Objetivo: analizar la relación costo-efectividad del etanercept en comparación con otras terapias biológicas para tratar la artritis reumatoide moderada o severa en pacientes con falla previa a fármacos antirreumáticos modificadores de la enfermedad. Métodos: se empleó un modelo farmacoeconómico basado en el análisis de decisiones para valorar la evolución clínica con etanercept, infliximab, adalimumab o tocilizumab para tratar artritis reumatoide moderada o severa. Los parámetros de efectividad fueron las tasas de mejoría igual o superior a 20 % (ACR 20) y de mejoría igual o superior a 70 % (ACR 70). Resultados: etanercept tuvo la mayor efectividad terapéutica: en 79.7 % de los pacientes se observó una ACR 20 y en 31.4 %, una ACR 70. También tuvo el menor costo asociado ($149 629.1 por paciente) y fue más costo-efectiva ($187 740.4 por éxito clínico para obtener ACR 20 y $476 525.8 por éxito clínico para obtener ACR 70) que las demás terapias biológicas. Conclusiones: el etanercept fue el fármaco más efectivo y menos costoso, por lo que resulta la opción terapéutica más eficiente, desde el punto de vista de la relación costo-efectividad media y en términos incrementales para el tratamiento de la artritis reumatoide.

Macrosomía fetal en madres no diabéticas: caracterización mínima / Fetal macrosomia in non-diabetic mothers: minimal characterization

Por macrosomía se entiende el desarrollo del cuerpo a tamaño exagerado, debido a diversas causas. Respecto a la madre y a su hijo también son diferentes los factores de riesgo que les afectan; por ello se efectuó un estudio retrospectivo y transversal, del tipo de casos (214 madres de recién nacidos macrosómicos) y controles (321 madres de neonatos con peso normal), seleccionados de un universo de 3 108 gestantes atendidas, durante el año 2011, en el Hospital Ginecoobstétrico Docente Tamara Bunke Bider de Santiago de Cuba. Se evaluaron 11 factores y se realizó el análisis estadístico requerido, basado en la razón de productos cruzados, con un intervalo de confianza de 95 por ciento, y la prueba de la Χ2, con 3 niveles de significación: I, p≤0,05 (estándar); II, p≤0,01 (alta) y III, p≤0,001 (muy alta). Los factores de riesgo identificados fueron: edad materna, hijos macrosómicos en partos previos, edad gestacional al parto, sexo del neonato y tipo de parto; además, los resultados de la morbilidad y mortalidad perinatal fueron satisfactorios, al compararlos con los de la bibliografía médica consultada(AU)

Macrosomia is an oversized body due to various causes. Different risk factors also affect mother and child, so that a retrospective and cross-sectional case-control study (214 mothers with macrosomic newborns and 321 mothers with normal weight infants) was carried out. They were selected from a total of 3 108 pregnant women attended in Tamara Bunke Bider Gynecoobstetric Teaching Hospital of Santiago de Cuba during 2011. 11 factors were evaluated and the required statistical analysis was performed, based on the odds ratio with a 95 percent confidence interval, and the chi-square test with 3 significance levels: I, p≤ 0.05 (standard); II, p≤ 0.01 (high) and III, p≤0.001 (very high). Risk factors identified were maternal age, macrosomic children in previous deliveries, gestational age at delivery, infant sex and type of delivery; in addition, the results of perinatal morbidity and mortality were satisfactory when compared with those of the literature reviewed.

Macrosomía fetal en madres no diabéticas. Caracterización mínima / Fetal macrosomia in non-diabetic mothers. Minimal characterization

Por macrosomía se entiende el desarrollo del cuerpo a tamaño exagerado, debido a diversas causas. Respecto a la madre y a su hijo también son diferentes los factores de riesgo que les afectan; por ello se efectuó un estudio retrospectivo y transversal, del tipo de casos (214 madres de recién nacidos macrosómicos) y controles (321 madres de neonatos con peso normal), seleccionados de un universo de 3 108 gestantes atendidas, durante el año 2011, en el Hospital Ginecoobstétrico Docente "Tamara Bunke Bider" de Santiago de Cuba. Se evaluaron 11 factores y se realizó el análisis estadístico requerido, basado en la razón de productos cruzados, con un intervalo de confianza de 95 %, y la prueba de la Χ², con 3 niveles de significación: I, p≤0,05 (estándar); II, p≤0,01 (alta) y III, p≤0,001 (muy alta). Los factores de riesgo identificados fueron: edad materna, hijos macrosómicos en partos previos, edad gestacional al parto, sexo del neonato y tipo de parto; además, los resultados de la morbilidad y mortalidad perinatal fueron satisfactorios, al compararlos con los de la bibliografía médica consultada.

Macrosomia is an oversized body due to various causes. Different risk factors also affect mother and child, so that a retrospective and cross-sectional case-control study (214 mothers with macrosomic newborns and 321 mothers with normal weight infants) was carried out. They were selected from a total of 3 108 pregnant women attended in "Tamara Bunke Bider" Gynecoobstetric Teaching Hospital of Santiago de Cuba during 2011. 11 factors were evaluated and the required statistical analysis was performed, based on the odds ratio with a 95% confidence interval, and the chi-square test with 3 significance levels: I, p≤ 0.05 (standard); II, p≤ 0.01 (high) and III, p≤0.001 (very high). Risk factors identified were maternal age, macrosomic children in previous deliveries, gestational age at delivery, infant sex and type of delivery; in addition, the results of perinatal morbidity and mortality were satisfactory when compared with those of the literature reviewed.

Análisis del costo y la efectividad de los esquemas de administración de factores de coagulación para el manejo de niños con hemofilia A en México / Cost-effectiveness analysis of prophylaxis vs. ''on demand'' approach in the management in children with hemophilia A in Mexico

Introducción. La hemofilia A es causada por la deficiencia del factor VIII. El tratamiento consiste principalmente en aumentar la concentración del FVIII en la sangre utilizando productos de remplazo. El objetivo de este trabajo fue estimar los beneficios clínicos y económicos del manejo profiláctico con factor VIII en niños con hemofilia A en México. Métodos. Se realizó la evaluación económica del manejo profiláctico (PROF) y del tratamiento sobre demanda (SD). Las estrategias comparadas fueron el manejo profiláctico -consistente en FVIII recombinante 25 UI/kg cada tercer día- vs. tratamiento sobre demanda -consistente en FVIII derivado de plasma 40 UI/kg. Se reportó el número de sangrados evitados (SE). Se empleó una tasa de descuento del 5%. Los resultados se expresaron en pesos mexicanos. Resultados. El costo de incremental de PROF respecto a SD fue de $7,727,554 pesos. El manejo con PROF ofrece una reducción de 112 SE frente al manejo de SD (162.9 vs. 50.7). El costo por SE fue de $68,876 pesos. Conclusiones. Un abordaje con PROF mejora la calidad de vida respecto al manejo SD y reduce el número de hemorragias que enfrentan los niños con hemofilia A. PROF es una alternativa costo-efectiva (RCEI $68,876 pesos) para reducir sangrados de acuerdo con la disponibilidad de pago establecida por las autoridades de salud en México.

Background. Hemophilia A is due to a deficiency of factor VIII. Treatment consists primarily of increasing the concentration of FVIII in the blood using replacement products. The aim of this study was to estimate the clinical and economic benefits of prophylactic management with factor VIII in children with hemophilia A in Mexico. We undertook this study to estimate the clinical and economic benefits of prophylactic management (PROF) with factor VIII (FVIII) in children with severe hemophilia in Mexico. Methods. We carried out an economic evaluation of PROF vs. treatment on demand (OD). The strategies compared were management with PROF consisting of recombinant FVIII (rFVIII) 25 IU kg every other day vs. OD management consisting of plasma-derived FVIII (pdFVIII) 40 IU kg. A Markov model was performed with a time horizon of 16 years in patients with severe hemophilia for 2 years, reporting the number of events of bleeding averted (BA). We used a discount rate of 5%. The results are expressed in Mexican pesos (2012). Results. The incremental cost of PROF regarding SD was $7,727,554 pesos. PROF management provides a reduction of 112 BA vs. OD management (162.9 vs. 50.7). Cost per BA was $68,876 pesos. Conclusions. Management with PROF reduces the number of bleeding events facing children with hemophilia A compared to OD management. PROF is a cost-effective alternative to reduce bleeding ($68,876 pesos per BA) according to the willingness to pay established by health authorities in Mexico.

Health care costs of osteopenia, osteoporosis, and fragility fractures in Mexico.

UNLABELLED: Different sources were used to estimate the 2010 health care costs of managing low bone density (osteopenia/osteoporosis) plus caring fragility fractures in Mexico at 411 million USD. Figures are projected to rise 42 % by 2020. Preventive and timely interventions are required to decrease the financial burden of these entities. INTRODUCTION: Osteopenia, osteoporosis, and fragility fractures (FF) are a public health concern. The study purpose was to estimate the health care costs of these conditions in Mexico during 2010 and project them to 2015 and 2020. METHODS: Prevalence of osteopenia and osteoporosis was derived from international data. The Mexican version of FRAX® algorithm was used to assess risk for a major FF (hip, clinical spine, forearm, and proximal humerus) in osteopenic and osteoporotic population aged over 40 years. The estimates were applied to national demographic projections. Only direct medical costs composed by routine non-pharmacological management of osteopenia/osteoporosis besides the costs owing to medical care of major FF were considered into the analysis. Resource use for managing osteopenia/osteoporosis was defined from local sources (clinical practice guidelines, published literature, and expert opinion); unit costs were gathered from official lists. Costs for medical care of FF were based on diagnosis-related groups. RESULTS: In population aged ≥40 years, prevalence of osteopenia and osteoporosis in 2010 was 32.8 and 8 %, respectively. A total of 75,763 FF occurred that year. Costs of managing osteopenia and osteoporosis were 154.9 million USD, whereas medical costs due to FF reached 256.2 million USD. Therefore, the annual health care costs of these entities in 2010 were 411 million USD. Total costs will be 19.2 % higher in 2015, and by 2020, the figures will have increased by 41.7 %. CONCLUSIONS: Low bone density entails substantial epidemiological and financial burden in Mexico, and their impact will grow considerably during the next years.

Inhibitors of the TAM subfamily of tyrosine kinases: synthesis and biological evaluation.

The TAM subfamily of Receptor Tyrosine Kinases (RTKs) contains three human proteins of therapeutical interest, Axl, Mer, and Tyro3. Our goal was to design a type II inhibitor specific for this family, i.e. able to interact with the allosteric pocket and with the hinge region of the kinase. We report the synthesis of several series of purine analogues of BMS-777607. The structural diversity of the designed inhibitors was expected to modify the interactions formed in the binding site and consequently to modulate their selectivity profiles. The most potent inhibitor 6g exhibits Kds of 39, 42, 65 and 200 nM against Axl, Mer, Met and Tyro3 respectively. Analysis of the affinity of 6g for active and inactive forms of Abl1, an RTK protein that does not belong to the TAM subfamily, together with the binding modes of 6g predicted by docking studies, indicates that 6g displays some selectivity for the TAM family and may act as a type II inhibitor.

Intraosseous access EZ-IO in a prehospital emergency service.

BACKGROUND: Several scientific and professional associations have made reports and recommendations to regulate the use of intraosseous (IO) access as an alternative to conventional intravenous access (IA) in emergency situations when IA cannot be obtained. It has been well documented that IO access is safe and effective for fluid resuscitation, drug delivery, and blood collection. IO access is attainable in all age groups. OBJECTIVE: The objective of this prospective study was to test the use of a semi-automatic IO infusion system (EZ-IO) as an alternative to vascular access in critical patients treated in a prehospital emergency setting. METHOD: This prospective, cross-sectional study included patients who required immediate peripheral vascular access. This study was performed by reviewing clinical records and through a questionnaire (created by and for nurses who perform the insertion with the EZ-IO). RESULTS: During the study period we identified 107 patients who underwent EZ-IO insertion (114 insertions were performed). Patients were predominantly male (66%) and middle aged (mean age 56 years; range 3-94). Overall, insertion was performed via the proximal tibia (49.4%) distal tibia (25.2%), radius (14.9%), and humerus (10.5%). During the study period, 14 insertions were performed in 2007, 44 in 2008, and 56 in 2009. A majority of patients (50.9%) had medical cardiac arrest, (25.4%) were injured trauma patients, and 12.3% had traumatic cardiac arrest. All patients were transported to a hospital with 2 sites of peripheral vascular access. The first site of access in these patients was IO (100% of cases) and the second site (in 79% of cases) was peripheral intravenous access. All EZ-IO insertions were achieved within 30 seconds and were successful upon the first attempt. CONCLUSION: The use of the EZ-IO provides a quick (100% performed within 30 seconds), easy, and reliable alternative to conventional venous access in critically ill patients. Traditional peripheral venous access requires a minimal preparation that can delay initial treatment in critically ill patients and cause possible interference with resuscitation. The main advantage of using EZ-IO is to obtain secure, immediate, noncollapsible peripheral venous access in critically ill patients. It is possible to obtain a second site of access such as peripheral venous access to administer fluids and drugs, which can improve survival rates.

Synthesis of 9,9'-[1,2-ethanediylbis(oxymethylene)]bis-2-amino-1,9-dihydro-6H-purin-6-one, an impurity of acyclovir.

The synthesis of 9,9'-[1,2-ethanediylbis(oxymethylene)]bis-2-amino-1,9-dihydro-6H-purin-6-one, a minor impurity of acyclovir, is described. Starting with commercial N-(9-acetyl-6-oxo-1H-purin-2-yl)acetamide, the process uses an acid catalysed phase transfer catalysis (PTC) process to produce the selective alkylation at the 9 position of the guanine ring.

[Economic analysis of parecoxib in the management of postsurgical pain in gynecology]. / Análisis económico de parecoxib en el tratamiento del dolor postoperatorio en ginecología.

BACKGROUND: Poorly managed postoperative pain has a negative impact in healing patients and costs of care. METHODS: A model to estimate economic and health consequences of parecoxib 40 mg and morphine 12 mg regarding ketorolac 30 mg, on the management of postoperative pain in gynecologic laparotomy surgery from the perspective of the Mexican Social Security Institute (IMSS) was developed. A systematic review to identify the proportion of patients that rated their analgesic treatment as "excellent" or "good" in the Patient Global Evaluation of Study Medication, 12 hours after administration of the analgesic (responders), was performed. The patients who rated "fair" or "poor" their treatment were administered additional 4 mg of morphine. Costs in the model correspond to the acquisition costs of analgesics in which the institution would incur. RESULTS: The proportion and cost per responder were: morphine: 14.44% and $192.79, ketorolac: 32.44% and $34.82, parecoxib: 35.51% and $121.25.Treatment with morphine was more expensive and less effective than both, ketorolac and parecoxib, while the cost per additional percent point of responders with parecoxib (compared to ketorolac) was $28.15. For the management of postoperative pain, ketorolac and parecoxib are more effective and less expensive than morphine, additionally parecoxib would be an alternative for patients with contraindication to ketorolac use. CONCLUSION: The management of postoperative pain with parecoxib is more effective and, in the context of IMSS, less expensive than morphine, also constitutes an alternative with a reasonable incremental cost compared to ketorolac.

[Risk factors associated with human immunodeficiency virus in men deprived of their liberty in Merida, Yucatan, Mexico]. / Factores de riesgo asociados al virus de inmunodeficiencia humana en hombres privados de su libertad en Mérida, Yucatán, México.

A case control study was conducted to know risk factors associated to HIV infection in Yucatan, Mexico jails. Repeated imprisonment, having more than eleven intercourses couples and having sex with other men were statistically related to HIV infection. Tattooing and intravenous drugs abuse were no significant risk factors.

Economic evaluation of duloxetine as a first-line treatment for painful diabetic peripheral neuropathy in Mexico.

OBJECTIVE: To perform an economic evaluation of duloxetine, pregabalin, and both branded and generic gabapentin for managing pain in patients with painful diabetic peripheral neuropathy (PDPN) in Mexico. RESEARCH DESIGN AND METHODS: The analysis was conducted using a 3-month decision model, which compares duloxetine 60 mg once daily (DUL), pregabalin 150 mg twice daily (PGB), and gabapentin 600 mg three-times daily (GBP) for PDPN patients with moderate-to-severe pain. A systematic review was performed and placebo-adjusted risk ratios for achieving good pain relief (GPR), adverse events (AE), and withdrawal owing to intolerable AE were calculated. Direct medical costs included drug acquisition and additional visits due to lack of efficacy (poor pain relief) or intolerable AE. Unit costs were taken from local sources. Adherence rates were used to estimate the expected drug costs. All costs are expressed in 2010 Mexican Pesos (MXN). Utility values drawn from published literature were applied to health states. The proportion of patients with GPR and quality-adjusted life years (QALY) were assessed. RESULTS: Branded-GBP was dominated by all the other options. PGB was more costly and less effective than DUL. Compared with branded-GBP and PGB, DUL led to savings of 1.01 and 1.74 million MXN (per 1000 patients). The incremental cost per QALY gained with DUL used instead of generic-GBP was $102 433 MXN. This amount is slightly lower than the estimated gross domestic product per capita in Mexico for 2010. During a second-order Monte Carlo simulation, DUL had the highest probability of being cost-effective (61%), followed by generic-GBP (25%) and PGB (14%). LIMITATIONS: Study limitations include a short timeframe and using data from different dosage schemes for GBP and PGB. CONCLUSIONS: This study suggests that DUL provides overall savings and better health outcomes compared with branded-GBP and PGB. Administering DUL rather than generic-GBP is a cost-effective intervention to manage PDPN in Mexico.

Costo Efectividad del Tratamiento de Tumores Neuroendócrinos Pancreáticos Avanzados no Operables con Sunitinib en México.

OBJECTIVES: Sunitinib had showed a substantial clinical benefit in patients with non-resectable pancreatic Neuroendocrine Tumors (NET). The objective of this study was to estimate the cost-effectiveness of sunitinib in the treatment of non-resectable pancreatic NET, from the perspective of the Social Security Mexican Institute (IMSS). METHODS: A Markov model (2-week cycles) was used to estimate the health and economic consequences of sunitinib 37.5mg/day+best supportive care (BSC) regarding placebo+BSC (ten-years horizon, discount rate: 5%). Effectiveness measures were: overall survival (OS), progression-free survival (PFS) and quality adjusted life years (QALY). Resource utilization (BSC, adverse events management, medical follow-up) was estimated through a survey with Mexican oncologists (n=10). Unit costs of medication and medical resources were obtained from institutional sources. Sensitivity analyses were performed and acceptability curves were constructed. RESULTS: Sunitinib+BSC gained 0.49 years (PFS), 1.18 years (OS) and 0.70 QALY against placebo+BSC. Sunitinib+BSC increased medical direct costs (2011 US$) per patient in $20,854, which was driven by acquisition costs of sunitinib and medical follow up before progression. ICER's were $42,157, $17,662 and $29,808 per progression-free year, life-year and QALY gained, respectively, which remained robust through±25% changes in main parameters. At willingness to pay higher than $40,000, $22,400 and $37,600 sunitinib+BSC becomes the most cost-effective alternative in regards to PFS, OS and QALYs, respectively. CONCLUSION: At IMSS, sunitinib+BSC would provide substantial clinical benefits to patients suffering unresectable pancreatic NET, although the latter would increase medical costs of treatment and clinical follow up.

Cost Utility of Sirolimus versus Tacrolimus for the Primary Prevention of Graft Rejection in Renal Transplant Recipients in Mexico.

OBJECTIVE: Therapies for end-stage renal disease improve quality of life, and survival. In Mexico, clinicians often must choose between different therapies without the availability of comparative outcomes evaluation. The present study evaluates the comparative cost-utility of sirolimus (SIR) versus tacrolimus (TAC) for the primary prevention of graft rejection in renal transplant recipients in Mexico. METHODS: We used modeling techniques to estimate the cost-effectiveness of SIR versus TAC to prevent graft rejection in patients with end-stage renal disease in the Mexican setting. The model estimates the cost of quality-adjusted life-year (QALY) per patient. We applied a 20-year horizon (1-year Markov cycles). Cost-effectiveness was expressed in terms of cost per QALY. All costs are presented in 2011 US dollars. Probabilistic sensitivity analyses were conducted. RESULTS: The total cost for the SIR treatment arm over the 20-year duration of the model is estimated to be $136,778. This compares with $142,624 for the TAC treatment arm, resulting in an incremental cost of SIR compared with that of TAC of-$5,846. Over 20 years, SIR was estimated to have 8.18 QALYs compared with 7.33 QALYs for TAC. The resulting incremental utility of SIR compared with that of TAC is 0.84 QALY gained. SIR is estimated to be both less costly and more effective than TAC, indicating that it is the dominant strategy. Notably, results suggest that SIR has a 78% probability of being dominant over the TAC strategy and a 100% probability of having an incremental cost-effectiveness ratio at or below $10,064 (1 GDP) per QALY. CONCLUSIONS: These analyses suggest that in the Mexican setting, the use of SIR in place of TAC for the prevention of graft rejection in this population is likely to be cost saving.

A successful emergency thoracotomy performed in the field.

An emergency thoracotomy (ET) is a surgical procedure rarely practiced outside a hospital. However, it can be the only way to resuscitate a patient who has suffered cardiac arrest due to penetrating chest trauma. SAMUR-Protección Civil is a two-tier Emergency Medical Service of Madrid, with Advance Life Support teams led by Emergency Physicians, Emergency Nurses and Paramedics. Over the last 3 years, medical teams from SAMUR have performed ET in six cases, after a short period of cardiac arrest, restoring cardiac output in two cases, and one patient with a normal neurological outcome. The following SAMUR protocol describes these emergency situations and details the case of the patient who was treated and discharged from hospital without any repercussions.