Cost-Utility Study of PCV13 Versus PPSV23 in Adults in Chile.

INTRODUCTION: Pneumococcal infections are a public health problem in older adults. In Chile there are two vaccines at this time, PPSV23 and PCV13. The first has lower immunogenicity and effectiveness in preventing pneumococcal pneumonia and a lower cost than PCV13. OBJECTIVE: To determine the cost-effectiveness of PCV13 versus PPSV23 in adults 18 years old and over in the Chilean Health System. MATERIAL AND METHOD: A cost-utility study was performed using the Markov model (population data for a time horizon of 10 years). Utilities and epidemiological data were obtained from the literature and costs from the Chilean Public sector. Vaccine's costs and quality-adjusted life years (QALYs) were determined and compared. RESULTS: PCV13 vaccination program in adults (≥18 years), generated savings of $42,195 USD and an increase of 6,820 QALYs, avoiding 107 cases of bacteremia, 13 meningitis, 6,706 inpatient pneumonia, 4,509 outpatient pneumonia and 1,189 deaths compared to PPSV23 without variation on sensitivity analysis on high impact variables. For the subgroup of patients over 65 years old PCV13 generates savings of $ 32,105.94USD and produces 5,430 QALYs more compared to PPSV23. CONCLUSION: PCV13 is dominant. A PCV13 vaccination program saves costs to the public system, reduces mortality and morbidity; these results are robust.

[Trend in cervical cancer mortality in Chile: application of joinpoint regression models]. / Tendencia de la mortalidad por cáncer de cuello uterino en Chile: aplicación de modelos de regresión joinpoint.

OBJECTIVE: To identify and model changes in the cervical cancer mortality trend in Chile between 1990 and 2009 in order to contribute to the design of health policies on cervical cancer. METHODS: The study analyzed deaths from cervical cancer in Chile between 1990 and 2009. The cases were identified by the codes ICD-9 180 and ICD-10 C-53. The population at risk was calculated on the basis of projections by the National Statistics Institute of Chile. Mortality was modeled using Poisson regression analysis, including the variables of age in decades starting at age 30 and time interval in calendar periods and the term of interaction between the two variables. A joinpoint regression model, stratified by age group, was used to assess changes in the trend. In both models, the annual percentage of change (APC) was used as a summary measure. RESULTS: During the period studied, the APC in Chile was -4%. Women aged 40 to 49 experienced the greatest reduction in mortality (incidence rate ratio = 0.98; P < 0.05) (reference group: women aged 30 to 39). Those with the least reduction in mortality were women over 80 (APC -1.18%). The joinpoint model identified six significant changes in the time trend for the women studied: the greatest reductions occurred in 1999-2002 and 2003-2009, with APCs of -6.9 and -4%, respectively. CONCLUSIONS: Mortality from cervical cancer exhibited a downward trend during the period studied, and the trend was more pronounced among women in the youngest age group.

Tendencia de la mortalidad por cáncer de cuello uterino en Chile: aplicación de modelos de regresión joinpoint / Trend in cervical cancer mortality in Chile: application of joinpoint regression models

OBJETIVO: Identificar y modelizar los cambios en la tendencia de las tasas de mortalidad por cáncer cervicouterino en Chile entre 1990 y 2009, para contribuir a diseñar políticas de salud en el ámbito de este cáncer. MÉTODOS: Se utilizaron las defunciones por cáncer cervicouterino ocurridas entre 1990 y 2009 en Chile. Los casos se identificaron utilizando los códigos CIE-9:180 y CIE-10: C-53. La población en riesgo se obtuvo de las proyecciones del Instituto Nacional de Estadística de Chile. La tasa de mortalidad se modelizó mediante la regresión de Poisson, incorporando la edad en decenios a partir de los 30 años, el tiempo (en años calendario) y el término de interacción entre ambas variables. Para evaluar los cambios en la tendencia se usó el modelo joinpoint estratificado por grupos de edad. En ambos modelos se empleó el porcentaje de cambio anual (PCA) como medida resumen. RESULTADOS: Durante el período estudiado, el PCA en Chile fue -4%. Las mujeres con mayor disminución de la mortalidad fueron las de 40 a 49 años (razón de tasas de incidencia = 0,98; P < 0,05) (grupo de referencia: mujeres de 30 a 39 años de edad). La menor reducción de la mortalidad se observó en las mayores de 80 años (PCA = -1,18%). El modelo joinpoint mostró seis cambios significativos en la tendencia temporal para el conjunto de mujeres: las disminuciones de mayor magnitud se observaron en los períodos 1999-2002 y 2003-2009, con PCA de -6,9 y -4%, respectivamente. CONCLUSIONES: La mortalidad por cáncer cervicouterino tiene una tendencia decreciente en el período estudiado y más pronunciada en las mujeres más jóvenes.

OBJECTIVE: To identify and model changes in the cervical cancer mortality trend in Chile between 1990 and 2009 in order to contribute to the design of health policies on cervical cancer. METHODS: The study analyzed deaths from cervical cancer in Chile between 1990 and 2009. The cases were identified by the codes ICD-9 180 and ICD-10 C-53. The population at risk was calculated on the basis of projections by the National Statistics Institute of Chile. Mortality was modeled using Poisson regression analysis, including the variables of age in decades starting at age 30 and time interval in calendar periods and the term of interaction between the two variables. A joinpoint regression model, stratified by age group, was used to assess changes in the trend. In both models, the annual percentage of change (APC) was used as a summary measure. RESULTS: During the period studied, the APC in Chile was -4%. Women aged 40 to 49 experienced the greatest reduction in mortality (incidence rate ratio = 0.98; P < 0.05) (reference group: women aged 30 to 39). Those with the least reduction in mortality were women over 80 (APC -1.18%). The joinpoint model identified six significant changes in the time trend for the women studied: the greatest reductions occurred in 1999-2002 and 2003-2009, with APCs of -6.9 and -4%, respectively. CONCLUSIONS: Mortality from cervical cancer exhibited a downward trend during the period studied, and the trend was more pronounced among women in the youngest age group.

[Evidence and decision making process]. / Evidencia y el proceso de toma de decisiones.

The history of Evidence-Based Medicine is briefly reviewed, and also the concept of evidence used in Evidence-Based Medicine and its relation with the decision making process. Evidence-Based Medicine stresses the examination of evidence from research, especially clinical research, because this kind of evidence is obtained using objective methods and can be criticized. This kind of evidence is used as a masterpiece, together with other elements like social, cultural and economical factors to make the best possible decision. Sometimes evidence and the decision making process are confounded, but in the decision process, objective and subjective elements are combined, to maximally reduce the influence of subjective components. This allows to make the most adequate decision for every patient.

[Octreotide administration and/or endoscopic treatment in cirrhotic patients with acute variceal bleeding: a multicentric study]. / Octreótido, tratamiento endoscópico o ambos en la hemorragia variceal activa en pacientes cirróticos: estudio multicéntrico.

BACKGROUND: Acute variceal bleeding in cirrhotic patients is an emergency with a high risk of rebleeding and death. Endoscopic procedures such as sclerotherapy or banding, combined or not with drugs such as octreotide could be considered. AIM: To assess the value of octreotide in the control of acute variceal bleeding. PATIENTS AND METHODS: Ninety-two patients were randomized into three groups: endoscopic therapy plus octreotide 50 microg/h bolus and continuous infusion for 5 days (n=36); octreotide (same dosage) (n=13) and endoscopic therapy only (banding and/or sclerotherapy) (n=43). RESULTS: Haemostasis at 24 hours was achieved in 97% of patients with combined treatment, 69% of patients receiving octreotide, and 93% of patients with endoscopic therapy (p=0.2). Three patients with combined treatment, four patients receiving octreotide and eight patients with endoscopic therapy, rebled during the first five days (p=0.15). The mean of blood units transfused was similar in the three groups. No differences were observed in hospital days and side effects. At 42 days of follow up, eight patients with endoscopic therapy, one patients with combined therapy and 2 patients receiving octreotide, died (p=NS). CONCLUSIONS: Octreotide is useful in the management of acute variceal bleeding. The absence of important side effects, renders it as a safe adjuvant treatment associated with endoscopic treatment.

Length of the esophagus in patients with gastroesophageal reflux disease and Barrett's esophagus compared to controls.

BACKGROUND: It is a current opinion among surgeons that the esophagus is shorter in patients with reflux disease and particularly in those with complicated Barrett's esophagus. However, objective evidence of this is scarce. Therefore we attempted to determine the occurrence and magnitude of this phenomenon among our patients. METHODS: One hundred ninety control subjects, 77 patients with severe erosive esophagitis, 74 with Barrett's esophagus, and 29 with complicated Barrett's esophagus (ulcer, stenosis) were grouped according to height. The length of the esophagus was determined by standard manometric study, measuring the distance from the crycopharingeal sphincter to the distal limit of the lower esophageal sphincter. Values were expressed in cm as the mean +/- SD. RESULTS: The esophageal length according to height was 1 to 2 cm shorter in patients compared to controls, but these differences were not significant. CONCLUSIONS: No differences were found between patients with progressive severity of the disease. This study confirms that the presence of a so-called "short esophagus" does not exist or is not relevant in our patients with gastroesophageal reflux disease, including those with complicated Barrett's esophagus.

[Intrarenal arterial doppler ultrasonography in cirrhotic patients with ascites, with and without hepatorenal syndrome]. / Ecotomografía Doppler arterial intrarrenal en pacientes cirróticos con ascitis, con y sin síndrome hepatorrenal.

BACKGROUND: The pathophysiological hallmark of the hepatorenal syndrome (HRS) is renal vasoconstriction. Doppler ultrasonography can be used to assess the vascular resistance in small renal intraparenchymal vessels through analysis of the Doppler waveform by a parameter termed Resistive Index (RI). We postulated that the RI could be important for the diagnosis and prognosis of HRS. AIMS: To assess the RI in cirrhotic patients with ascites, with and without HRS. PATIENTS AND METHODS: We studied 48 cirrhotics with ascites, of whom 12 were with and 36 without HRS and other 23 were normal subjects. We measured the intrarenal arterial RI (Resistive index = Peak systolic velocity - Minimum diastolic velocity/Peak systolic velocity) with color Doppler ultrasonography after visualization of interlobular or arcuate arteries. It was considered abnormal when higher than 0.70. RESULTS: The RI values, mean and SD) were: normal subjects: 0.58 +/- 0.05, cirrhotics with ascites: 0.65 +/- 0.05 and cirrhotics with ascites and HRS: 0.78 +/- 0.11. Patients with HRS had significantly higher values than those without HRS (p < 0.001). The Relative Risk of developing the HRS in patients with a RI > or = 0.70 were 3.32 (CI 95% = 1.79-6.2) CONCLUSIONS: The RI was useful in patients with cirrhosis and ascites for the prognosis of HRS and could suggest diagnosis of HRS with values of 0.78 or higher, if other clinical conditions that produce renal vasoconstriction are excluded.