Quality of life and cost-effectiveness analysis of topical tranexamic acid and fibrin glue in femur fracture surgery.

BACKGROUND: We assessed quality of life (QoL) of patients undergoing surgery for proximal femur fracture and performed a cost-effectiveness analysis of haemostatic drugs for reducing postoperative bleeding. METHODS: We analysed data from an open, multicentre, parallel, randomized controlled clinical trial (RCT) that assessed the efficacy and safety of tranexamic acid (TXA group) and fibrin glue (FG group) administered topically prior to surgical closure, compared with usual haemostasis methods (control group). For this study we conducted a cost-effectiveness analysis of these interventions from the Spanish Health System perspective, using a time horizon of 12 months. The cost was reported in $US purchasing power parity (USPPP). We calculated the incremental cost-effectiveness ratio (ICER) per QALY (quality-adjusted life-year). RESULTS: We included 134 consecutive patients from February 2013 to March 2015: 42 patients in the TXA group, 46 in the FG group, and 46 in the control group. Before the fracture, EuroQol visual analogue scale (EQ-VAS) health questionnaire score was 68.6. During the 12 months post-surgery, the intragroup EQ-VAS improved, but without reaching pre-fracture values. There were no differences between groups for EQ-VAS and EuroQol 5 dimensions 5 levels (EQ-5D-5L) health questionnaire score, nor in hospital stay costs or medical complication costs. Nevertheless, the cost of one FG treatment was significantly higher (399.1 $USPPP) than the cost of TXA (12.9 $USPPP) or usual haemostasis (0 $USPPP). When comparing the cost-effectiveness of the interventions, FG was ruled out by simple dominance since it was more costly (13,314.7 $USPPP) than TXA (13,295.2 $USPPP) and less effective (utilities of 0.0532 vs. 0.0734, respectively). TXA compared to usual haemostasis had an ICER of 15,289.6 $USPPP per QALY). CONCLUSIONS: There were no significant differences between the intervention groups in terms of postoperative changes in QoL. However, topical TXA was more cost-effective than FG or usual haemostasis. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02150720. Date of registration 30/05/2014. Retrospectively registered.

Galectin-3 Is Associated with Cardiovascular Events in Post-Acute Coronary Syndrome Patients with Type-2 Diabetes.

INTRODUCTION: Type-2 diabetes mellitus (T2DM) is associated with early and severe atherosclerosis. However, few biomarkers can predict cardiovascular events in this population. METHODS: We followed 964 patients with coronary artery disease (CAD), assessing plasma levels of galectin-3, monocyte chemoattractant protein-1 (MCP-1), and N-terminal fragment of brain natriuretic peptide (NT-proBNP) at baseline. The secondary outcomes were acute ischemia and heart failure or death. The primary outcome was the combination of the secondary outcomes. RESULTS: Two hundred thirty-two patients had T2DM. Patients with T2DM showed higher MCP-1 (144 (113-195) vs. 133 (105-173) pg/mL, p = 0.006) and galectin-3 (8.3 (6.5-10.5) vs. 7.8 (5.9-9.8) ng/mL, p = 0.049) levels as compared to patients without diabetes. Median follow-up was 5.39 years (2.81-6.92). Galectin-3 levels were associated with increased risk of the primary outcome in T2DM patients (Hazard ratio (HR) 1.57 (1.07-2.30); p = 0.022), along with a history of cerebrovascular events. Treatment with clopidogrel was associated with lower risk. In contrast, NT-proBNP and MCP-1, but not galectin-3, were related to increased risk of the event in nondiabetic patients (HR 1.21 (1.04-1.42); p = 0.017 and HR 1.23 (1.05-1.44); p = 0.012, respectively), along with male sex and age. Galectin-3 was also the only biomarker associated with the development of acute ischemic events and heart failure or death in T2DM patients, while, in nondiabetics, MCP-1 and NT-proBNP, respectively, were related to these events. CONCLUSION: In CAD patients, galectin-3 plasma levels are associated with cardiovascular events in patients with T2DM, and MCP-1 and NT-proBNP in those without T2DM.

Molybdenum Cofactor Deficiency: Mega Cisterna Magna in Two Consecutive Pregnancies and Review of the Literature.

The molybdenum cofactor deficiency is an autosomal recessive disease, characterized by rapidly progressive and severe neurological damage that mimics a hypoxic-ischemic encephalopathy due to the accumulation of toxic metabolites that cause rapid neurodegeneration after the delivery. It is eventually lethal, in a similar way to the rare isolated sulfite oxidase deficiency. This serious pathology usually causes death in the immediate neonatal period in the more severe variants. We report a case of two consecutive pregnancies with enlarged cisterna magna as the only prenatal pathological finding since 26 weeks of gestation (WG) and the subsequent death of the newborns in the first week after birth. After the second pregnancy, we reached the diagnosis of molybdenum cofactor deficiency due to MOCS1 gene mutation. According to the cases reported in the literature, this is the case with the earliest neuroimage prenatal findings.

Socio-economic impact on women diagnosed and treated for breast cancer: a cross-sectional study.

INTRODUCTION: The increase in breast cancer survival poses a challenge for patients to be able to rejoin their professional and social life in very similar conditions to those before diagnosis. The aim of this study is to assess short- and medium-term social, economic and professional impact of BC among women diagnosed with it. METHODS: A cross-sectional descriptive study using QLQ-C30, QLQ-BR23, and MOS-SSS instruments and a semi-structured interview in women diagnosed in years 2011, 2014, and 2016 in Hospital de la Santa Creu i Sant Pau in Barcelona (Spain). RESULTS: 175 patients were included with a mean age of 55. About 62.8% were married or coupled, 76% were living with their family unit, and 52.6% denied changes in their living situation. The mean Support Global Index was 74.7% and 78.8% before and after diagnosis, respectively. The mean global quality of life (QOL) was 67.3%, outstanding insomnia as the main symptom (X > 30%) and sexual function as the most affected dimension. At the moment of diagnosis, two-thirds of patients were working. After diagnosis, 87.5% stopped working, 39.4% were off work for 7-12 months, and only 50% returned to work. Multivariate analysis identified working as the most associated variable with a good QOL. CONCLUSIONS: QOL among women diagnosed with breast cancer is quite high and stable. Nevertheless, there are some very relevant aspects to QOL that need to be considered whilst caring for patients with BC to achieve rehabilitation as complete and comprehensive as possible.

Platelet-lymphocyte and neutrophi-lymphocyte ratios are prognostic but not predictive of response to abiraterone acetate in metastatic castration-resistant prostate cancer

Purpose. Recently neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have been reported to be inflammatory parameters that confer poorer outcome in metastatic castration-resistant prostate cancer (mCPRPC). However, these ratios have not been analyzed in patients treated with abiraterone acetate. We explored the relationship between different values of PLR and NLR and survival in mCPRCP treated with abiraterone and their possible relation with a prostate specific antigen (PSA) response. Methods. We retrospectively analyzed 101 patients with mCRPC treated with abiraterone from January of 2012 to November of 2015 in two different hospitals. A cut-off value of 5 for NLR and 150 for PLR were used to compare survival by Kaplan-Meier method. Moreover, an association between these cut-off values and the PSA response was analyzed by a χ2 test. Results. In the case of NLR, the median DFS were 12, 1 months for NLR <5 and 7 months for NLR ≥5, p = 0.061. The median OS were 23.9 months for NLR <5 and 16.3 months for NLR ≥5, p = 0.046. In the case of PLR, the median DFS were 11.8 months for PLR <150 and 10.6 months for PLR ≥150, p = 0.549. The median OS were 27.4 months for PLR <150 and 15.9 months for PLR ≥150, p = 0.005. It was not observed a correlation between the different cut-off values of PLR or NLR and a PSA response ≥25% (p = 0.31). Conclusions. It is shown a better prognostic relationship between PLR and NLR low values and OS that is statistically significant in mCPRC patients treated with abiraterone. Furthermore, it was not shown a relation between PLR and NLR values and PSA response (AU)

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Platelet-lymphocyte and neutrophil-lymphocyte ratios are prognostic but not predictive of response to abiraterone acetate in metastatic castration-resistant prostate cancer.

PURPOSE: Recently neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have been reported to be inflammatory parameters that confer poorer outcome in metastatic castration-resistant prostate cancer (mCPRPC). However, these ratios have not been analyzed in patients treated with abiraterone acetate. We explored the relationship between different values of PLR and NLR and survival in mCPRCP treated with abiraterone and their possible relation with a prostate specific antigen (PSA) response. METHODS: We retrospectively analyzed 101 patients with mCRPC treated with abiraterone from January of 2012 to November of 2015 in two different hospitals. A cut-off value of 5 for NLR and 150 for PLR were used to compare survival by Kaplan-Meier method. Moreover, an association between these cut-off values and the PSA response was analyzed by a χ 2 test. RESULTS: In the case of NLR, the median DFS were 12, 1 months for NLR <5 and 7 months for NLR ≥5, p = 0.061. The median OS were 23.9 months for NLR <5 and 16.3 months for NLR ≥5, p = 0.046. In the case of PLR, the median DFS were 11.8 months for PLR <150 and 10.6 months for PLR ≥150, p = 0.549. The median OS were 27.4 months for PLR <150 and 15.9 months for PLR ≥150, p = 0.005. It was not observed a correlation between the different cut-off values of PLR or NLR and a PSA response ≥25% (p = 0.31). CONCLUSIONS: It is shown a better prognostic relationship between PLR and NLR low values and OS that is statistically significant in mCPRC patients treated with abiraterone. Furthermore, it was not shown a relation between PLR and NLR values and PSA response.

Input of pharmaceuticals through coastal surface watercourses into a Mediterranean lagoon (Mar Menor, SE Spain): sources and seasonal variations.

The seasonal occurrence and distribution of 69 pharmaceuticals along coastal watercourses during 6 sampling campaigns and their input through El Albujón watercourse to the Mar Menor lagoon were determined by UPLC-MS-MS, considering a total of 115 water samples. The major source of pharmaceuticals running into this watercourse was an effluent from the Los Alcazares WWTP, although other sources were also present (runoffs, excess water from irrigation, etc.). In this urban and agriculturally influenced watercourse different pharmaceutical distribution profiles were detected according to their attenuation, which depended on physicochemical water conditions, pollutant input variation, biodegradation and photodegradation rates of pollutants, etc. The less recalcitrant compounds in this study (macrolides, ß-blockers, etc.) showed a relevant seasonal variability as a consequence of dissipation processes (degradation, sorption, etc.). Attenuation was lower, however, for diclofenac, carbamazepine, lorazepam, valsartan, sulfamethoxazole among others, due to their known lower degradability and sorption onto particulate matter, according to previous studies. The maximum concentrations detected were higher than 1000 ng L(-1) for azithromycin, clarithromycin, valsartan, acetaminophen and ibuprofen. These high concentration levels were favored by the limited dilution in this low flow system, and consequently some of them could pose an acute risk to the biota of this watercourse. Considering data from 2009 to 2010, it has been estimated that a total of 11.3 kg of pharmaceuticals access the Mar Menor lagoon annually through the El Albujón watercourse. The highest proportion of this input corresponded to antibiotics (46%), followed by antihypertensives (20%) and diuretics (18%).

Caso clínico interactivo. Trastorno de comportamiento durante el sueño en paciente joven / No disponible

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Linezolid plus rifampin as a salvage therapy in prosthetic joint infections treated without removing the implant.

The aim of this study is to describe our experience with linezolid plus rifampin as a salvage therapy in prosthetic joint infections (PJIs) when other antibiotic regimens failed or were not tolerated. A total of 161 patients with a documented prosthetic joint infection were diagnosed with a PJI and prospectively followed up from January 2000 to April 2007. Clinical characteristics, inflammatory markers, microbiological and radiological data, and antibiotic treatment were recorded. After a 2-year follow-up, patients were classified as cured when the prosthesis was not removed, symptoms of infection disappeared, and inflammatory parameters were within the normal range. Any other outcome was considered a failure. The mean age of the entire cohort (n = 161) was 67 years. Ninety-five episodes were on a knee prosthesis (59%), and 66 were on a hip prosthesis (41%). A total of 49 patients received linezolid plus rifampin: 45 due to failure of the previous antibiotic regimen and 4 due to an adverse event associated with the prior antibiotics. In no case was the implant removed. The mean (standard deviation) duration of treatment was 80.2 (29.7) days. The success rate after 24 months of follow-up was 69.4% (34/49 patients). Three patients developed thrombocytopenia and 3 developed anemia; however, it was not necessary to stop linezolid. Linezolid plus rifampin is an alternative salvage therapy when the implant is not removed.

El conocimiento de la morbilidad en atención primaria como ayuda para la planificación y gestión de los servicios / The knowledge of morbidity in Primary Care as an aid in the planning and management of the services

Introducción: El análisis de la morbilidad y la gestión de su conocimiento es una antigua aspiración en atención primaria (AP). La unidad de agrupación (visita, episodio, paciente), el sistema de clasificación de diagnósticos y el avance de las tecnologías de la información, son los aspectos que más han condicionado el desarrollo de los sistemas de clasificación (case-mix). El objetivo ha sido comprobar la factibilidad, de los Adjusted Clinical Groups (ACG) de la Universidad de Johns Hopkins, como instrumento para el análisis de la morbilidad, explorando en qué medida la información obtenida y su conocimiento nos puede ser de utilidad para la planificación y gestión de los servicios de AP.MétodosDurante un año se observaron 43.556 pacientes adscritos a medicina de familia de cinco zonas de salud del área de Tenerife, estableciendo comparaciones entre zonas de salud y cupos de pacientes. Para el análisis se utiliza el Software ACG (versión 7.1), así como procedimientos de estadística descriptiva, ajuste de tasas y análisis multivariante.ResultadosSe constatan importantes diferencias entre zonas y cupos con respecto a la carga de enfermedad. Los ACG explicaron en relación al consumo de recursos para el conjunto de pacientes: el 0,46 de las visitas y el 0,26 para el coste de la prescripción de farmacia (r2 ajustada p<0,001), similar al obtenido en otros estudios.ConclusionesConsideramos que esta herramienta (ACG) puede ser de gran utilidad, al facilitar las tareas de gestión y planificación de los servicios(AU)

Introduction: The analysis of the morbidity and management of its knowledge is an old aspiration in Primary Care. The grouping unit (visit, episode, patient), diagnosis classification system and the advance in information technology are the most important aspects conditioning the development of the classification system (case-mix). We have aimed to verify the feasibility of Adjusted Clinical Groups (ACG) of the Johns Hopkins University as an instrument for the analysis of morbidity and to study how much the information obtained and knowledge of it can be of use to us for the planning and management of services in primary care.MethodsDuring a one year period, 43,556 patients assigned to family medicine of five Health Care Zones of the area of Tenerife were observed. Comparisons were established between the Health Care Zones and quotas of patients assigned to the family physicians. The ACG software, version 7.1, was used for the analysis as well as descriptive statistics procedures, rate adjustment and multivariate analysis.ResultsImportant differences were found between the Zones and quotas in relationship to disease burden. In relationship to the resource usage for the sets of patients, the ACG explained 0.46 of the visits and 0.26 for the cost of the prescription of pharmacy (adjusted r2, p<0.001). These results are similar to those obtained in other studies.ConclusionsWe consider that this tool (ACG) can be very useful because it facilitates the tasks of management and planning of health services(AU)

Production of photocurrent due to intermediate-to-conduction-band transitions: a demonstration of a key operating principle of the intermediate-band solar cell.

We present intermediate-band solar cells manufactured using quantum dot technology that show for the first time the production of photocurrent when two sub-band-gap energy photons are absorbed simultaneously. One photon produces an optical transition from the intermediate-band to the conduction band while the second pumps an electron from the valence band to the intermediate-band. The detection of this two-photon absorption process is essential to verify the principles of operation of the intermediate-band solar cell. The phenomenon is the cornerstone physical principle that ultimately allows the production of photocurrent in a solar cell by below band gap photon absorption, without degradation of its output voltage.

Remifentanilo vs. bloqueo central epidural para control del dolor postoperatorio en cirugía vascular de urgencias / Remifentanyl versus epidural central blockade for the management of postoperative pain in emergency vascular surgery

Introducción:El correcto tratamiento del dolor postoperatorio constituyeuna prioridad dentro de los objetivos del anestesiólogo.En pacientes con patología vascular severa quirúrgica,el tratamiento analgésico efectivo se suele realizar mediantebloqueo continuo epidural. Sin embargo, la administraciónde analgésicos, tanto opiáceos como no opiáceos, porvía intravenosa, es una alternativa a la vía epidural cuandoesta es desestimada.Caso clínico:Presentamos el caso de un paciente varón de 63 añosportador de un bypass fémoro-poplíteo a primera porciónen miembro inferior izquierdo, el cual es intervenido quirúrgicamentey con carácter urgente tras el diagnóstico defalso aneurisma séptico de arteria iliaca izquierda con roturade anastomosis fémoro-poplítea.Se optó por una anestesia general basada en la analgesiacon remifentanilo frente a bloqueo central epidural dadoel carácter urgente de la cirugía y la ingesta habitual deantiagregantes plaquetarios. Se planificó como estrategiaanalgésica postoperatoria la administración de remifentaniloa dosis sedoanalgésicas (< 0,2 microg.kg-1.min-1).El paciente ingresó en la URPA con ventilación espontánea,extubado, presentando un EVA de 2-3 puntos. A las12 horas de su ingreso en URPA el paciente fue reintervenidopor presentar signos clínicos evidentes de isquemiaaguda en MMII. A pesar de ello, el estado de confort y lapuntuación EVA no variaron en ese periodo de tiempo.Discusión:El clorhidrato de remifentanilo es un opioide de acciónultracorta con elevada potencia analgésica. Debido a suspropiedades farmacocinéticas es un fármaco predecible enel inicio de acción y en la desaparición de sus efectos, independientementede la infusión o la dosis total administrada.Dada la ausencia de efecto analgésico residual tras anestesiageneral con este fármaco, es preciso establecer unadecuado plan analgésico postoperatorio. Remifentanilo adosis inferiores a 0,2 microg.kg-1.min-1 permite optimizar laanalgesia y confort de los pacientes en la URPA, siendouna alternativa al uso del bloqueo central epidural paracontrol del dolor postoperatorio en cirugía vascular de urgencias

Introduction:The appropriate management of postoperative pain is apriority among the objectives of the anesthesiologist. In patientswith severe surgical vascular pathology, an effectiveanalgesic treatment is usually provided with epidural continuousblockade. However, the intravenous administrationof analgesics, either opiates or non opiates, is an alternativeto the epidural route when this has to be dismissed.Clinical case:We present the case of a 63-years old male patient carryinga femoro-popliteus bypass in the first portion of theleft lower limb that underwent emergency surgery after beingdiagnosed of a false septic aneurysm in the left iliacartery with breakage of the femoro-popliteus anastomosis.General anesthesia based on remifentanyl was decidedinstead of epidural central blockade due to the urgent natureof the surgery and the regular intake of antiplatelet aggregants.The administration of fentanyl at sedoanalgesicdoses (<0,2 microg.kg-1.min-1) was planned as postoperativeanalgesic strategy .The patient entered in the APPU extubated, with spontaneousventilation and a VAS score of 2-3. Twelve hoursafter his admittance to the APPU, the patient underwentsurgery due to the presence of clinical signs that clearlysuggested an acute ischemia in MM.II. Despite this, the degreeof comfort and the VAS score did not changed duringthat period.Discussion:Remifentanyl chlorhidrate is an opiate with an extremelyshort action and a great analgesic power. Due to itspharmacokinetic properties, it is a predictable drug interms of the onset of its action and the end of its effects,regardless the infusion or the total dose administered.Given the lack of a residual analgesic effect after thegeneral anesthesia with this drug, an appropriate postoperativeanalgesic plan must be established. Remifentanyl atdoses < 0,2 microg.kg-1.min-1 allows to optimize the analgesiaand comfort of patients in the APPU and, hence, it is analternative to epidural central blockade for the managementof postoperative pain in emergency vascular surgery

Duplicación quística de yeyuno asociada a malrotación intestinal: presentación como abdomen agudo neonatal / Jejunal duplication cyst associated with intestinal malrotation: presentation as neonatal acute abdomen

La malrotación intestinal es una eventualidad frecuente que constituye una causa predominante de obstrucción intestinal alta en el recién nacido. Por otro lado, las duplicaciones digestivas son malformaciones congénitas infrecuentes cuyo diagnóstico clínico es dificultoso. La asociación de duplicación intestinal y malrotación es extremadamente rara, habiéndose descrito tan sólo 12 casos previos. Presentamos el caso de una recién nacida que debutó con obstrucción intestinal alta por vólvulo de intestino medio asociado a duplicación yeyunal quística, que evolucionó satisfactoriamente tras la intervención quirúrgica (AU)

Despertar intraoperatorio: Presentación de un caso en cirugía pediátrica / Awareness: Report of a case in pediatric surgery

El despertar intraoperatorio (DIO) o 'Awareness' se define como la recuperación de la consciencia durante una anestesia general. Se presenta el caso de un paciente de 11 años intervenido de hipospadias, que tras la educción anestésica, relató hechos que denotaban claramente consciencia intraoperatoria, sin acompañarse de dolor, ansiedad, síntomas displacenteros ni alteración psicoconductal a largo plazo. Resaltamos aspectos fisiopatológicos, diagnósticos y preventivos de esta rara complicación en cirugía pediátrica (AU)

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[Intraoperative awakening: report of a case in pediatric surgery]. / Despertar intraoperatorio: presentación de un caso en cirugía pediátrica.

Intraoperatory awakening or awareness can be defined as recovering of conscience during general anesthesia. We report such a case happened in a 11 year-old boy during a hypospadias repair. After anesthetic education he related intraoperatory conscience without pain, anxiety, displeasing symptoms or long-term psychoconductal distress. We remark fisiopathology, diagnostic and preventive aspects of this rare event in pediatric surgery.

Análisis de cataratas infantiles operadas en el servicio de oftalmología del Hospital Clínico Regional de Concepción / Analysis of child cataracts operated at ophtalmological service of Hospital Clínico Regional, Concepción

Presentamos un estudio retrospectivo de cataratas infantiles operadas en pacientes menores de 15 años en el Hospital Regional de Concepción entre 1983-1994. Dividimos los pacientes en 2 grupos, encontrando 46 casos con cataratas bilaterales (79 cirugías) y 6o casos con cataratas unilaterales (60 cirugías). Analizamos edad de detección de las cataratas, edad en el momento de la cirugía, técnica y número de cirugías en cada caso, etiología, método de corrección afáquica, número de control postoperatorio y resultado visual aparte de otros datos disponibles. Los resultados mostraron que el principal problema es el seguimiento postoperatorio de estos pacientes y la pobre corrección afáquica. Sugerimos la formación de una unidad especial para controles, tratamiento de ambliopía y corrección afáquica de estos niños

[Lingual hamartoma]. / Hamartoma lingual.

The hamartoma is a benign tumor resulting of a mixture of normal and mature tissues and cells, sitting on an organ or tissue showing identical cell components. From the perusal done of the bibliography they appear as rare malformations basically compound of fibrous tissue, fat, acini of salivary glands and smooth muscle.