Costos de atención y rehabilitación de pacientes con lesiones por accidentes de tránsito en el mundo / Treatment and Rehabilitation costs of patients with injuries caused by traffic accidents in the world / Custos de atendimento e reabilitação de pacientes com ferimentos por acidentes de transido no mundo

Objetivo: Conocer los costos directos (CD) e indirectos (CI) de la atención de pacientes con lesiones por accidentes de tránsito (AT) en el mundo. Métodos: Se realizó una revisión sistemática en PubMed, Embase, Centre for Reviews and Dissemination, Journal Storage y Scielo de estudios de costos de atención de víctimas de AT mayores de 16 años, entre 2008 y 2013. La calidad de los estudios se evaluó con criterios extraídos de Drummond y col, y del " Consolidated Health Economic Evaluation Reporting Standards statement (CHEERS)" y otros definidos por los autores. Se evaluaron los CD, los CI. La carga de la enfermedad (CE), se hizo con los Años de Vida Ajustados por Discapacidad (AVAD), y Años de Vida ajustados por Calidad (AVAC). Se analizaron los costos generados por discapacidad/rehabilitación y Trauma craneoencefálico (TEC). Los costos monetarios en dólares americanos (USD) de 2010 ajustados por inflación. Resultados: Se analizaron 14 estudios, seis de buena calidad. Se encontraron estudios con 567.000 pacientes y 10 años de duración, costos directos de 48.082 e indirectos de 29.706 USD por paciente; los costos indirectos superaron los directos. La carga de la enfermedad mostró amplia variabilidad; en un estudio el 60% de los pacientes con TEC grave y 20% moderado quedaron con discapacidad corto plazo y en otro el 4,6% quedó con discapacidad a largo plazo. Conclusiones: Existe gran heterogeneidad en los estudios, no hay consenso para evaluar la calidad de estos estudios. Los costos indirectos de accidentes de tránsito superan los directos. Los costos derivados de discapacidad y rehabilitación son poco evaluados.

Objective: to know the direct (DC) and indirect costs (IC) generated by the treatment of patients with moderate or severe injuries caused by traffic accidents (TA) in the world. Methodology: a systematic review of studies assessing the costs of treating victims of traffic accidents older than 16 between 2008 and 2013 was conducted using the PubMed, Embase, Centre for Reviews and Dissemination, Journal Storage and Scielo databases. The quality of the studies was assessed using criteria from Drummond and col, as well as the "Consolidated Health Economic Evaluation Reporting Standards statement (CHEERS)" and other mechanisms defined by the authors. DCs and ICs were assessed. The burden of disease (BD) was obtained with the disability-adjusted life year (DALY), and the quality-adjusted life-year (QALY). The costs generated by disability /rehabilitation and traumatic brain injury (TBI) were analyzed. The monetary costs were expressed in 2010 US dollars (USD) adjusted for inflation. Results: 14 studies were analyzed, 6 of which had a good quality. We found studies with up to 567.000 patients and a duration of 10 years. Direct costs were up to USD 48.082 and indirect costs up to USD 29.706 per patient; the direct costs were exceeded by the indirect costs. The burden of disease showed high variability. In one study, 60% of the patients with severe TBI and 20% with moderate TBI had short term disability; in another study 4.6% of the patients sustained long-term disability. Conclusions: there is great heterogeneity in the cost studies. There is no consensus for assessing the quality of these studies. The indirect costs incurred in traffic accidents are greater than direct costs. The costs of disability and rehabilitation are poorly assessed.

Objetivo: conhecer os custos diretos (cd) e indiretos (ci) do atendimento de pacientes com ferimentos por acidentes de trânsito (at) no mundo. Metodologia: realizou-se uma revisão sistemática em PubMed, Embase, Centre for Reviews and Dissemination, Journal Storage e Storage de estudos de custos de atendimento de cítimas de at com mais de 16 anos, entre 2 e 2013. A qualidade dos estudos foi avaliada com critérios extraídos de Drummond y col e do "Consolidated Health Economic Evaluation Reporting Standards statement (cheers)" e com outros definidos pelos autores. Avaliaram-se os DC, os CI. A carga da doença (cd) realizou-se com os Anos de Vida Ajustados por Deficiência (avad), e com Anos de Vida ajustados por Qualidade (avaq). Analisaram-se os custos gerados por Deficiência/reabilitação e Traumatismos cranioencefálicos (tce). Os custos monetários em dólares americanos (usd) de 2010 ajustados por inflação. Resultados : analisaram-se 14 estudos, seis de boa qualidade. Encontraram-se estudos com 567.000 pacientes e 10 anos de duração, custos diretos de 48.082 e indiretos de 29.706 usd por paciente. Os custos indiretos foram superiores aos diretos. A carga da doença mostrou gandre variabilidade. Em um estudo, 60% dos pacientes com tce sério e 20% moderado ficaram com deficiência de curto prazo e em outro, 4,6% ficou com Deficiência de longo prazo. Conclusão: existe grande heterogeneidade nos estudos, não há consenso para avaliar a qualidade destes estudos. Os custos indiretos de acidentes de trânsito são superiores os indiretos. Os custos derivados de Deficiência e de reabilitação são pouco avaliados.

Comparación de la toma seriada de presión arterial y la monitorización ambulatoria para el diagnóstico de hipertensión esencial en una población colombiana / Comparison between serial measurement of blood pressure and ambulatory monitoring for the diagnosis of essential hypertension in a colombian population

Objetivos: comparar la toma seriada de la presión arterial en consultorio con la monitorización ambulatoria de la presión arterial durante 24 horas para el diagnóstico de hipertensión arterial con base en los criterios definidos en las guías de la European Society of Hypertension-European Society of Cardiology (ESH-ESC) y el Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-VII), en una población adulta, en la ciudad de Medellín. Métodos: se estudiaron 66 pacientes entre los 18 y 65 años, sin diagnóstico previo de hipertensión arterial ni factores de riesgo para enfermedad cardiovascular, por medio de tres métodos de toma de la presión arterial (ocasional, toma seriada, monitorización ambulatoria), los cuales se compararon según los diferentes métodos expuestos en las guías JNC-VII, ESH-ESC y de Atención de la Hipertensión Arterial, del Ministerio de la Protección Social de Colombia. Resultados: se estudiaron inicialmente 3.589 pacientes con una toma ocasional de la presión arterial, de los cuales 680 tenía cifras de tensión > 138/88. De éstos se citaron 346 para la toma seriada de la presión arterial; los restantes no cumplían con criterios de inclusión. Los 66 pacientes con promedio de presión arterial >140/90 clasificaron para una monitorización ambulatoria de la presión arterial. La sensibilidad de la toma seriada de la presión arterial interpretada por cualesquiera de las guías utilizadas, fue superior a 88% y la especificidad inferior a 22%; el coeficiente de probabilidad positivo fue cercano a 1 en todos los casos. Conclusión: la toma seriada de la presión arterial comparada con la monitorización ambulatoria de la presión arterial, tiene alta sensibilidad (mayor de 88%) y baja especificidad (menor de 22%) con base en las tres guías clínicas utilizadas, y no es recomendable como prueba de referencia.

Objectives: to compare serial measurement of blood pressure in office with ambulatory blood pressure over 24 hours for the diagnosis of hypertension based on the criteria defined in the guidelines of the European Society of Hypertension - European Society of Cardiology (ESH -ESC) and the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC -VII) in an adult population in the city of Medellin. Methods: 66 patients between 18 and 65 years, with no previous diagnosis of hypertension nor risk factors for cardiovascular disease were studied, using three methods of blood pressure measurement (occasional, serial measurement of blood pressure, ambulatory blood pressure monitoring), which were compared according to the different methods outlined in JNC -VII guidelines, ESH-ESC guidelines of Hypertension Care from the Ministry of Social Protection of Colombia. Results: 3,589 patients were studied initially with occasional measurement of blood pressure, of which 680 had blood pressure levels > 138/88. Of these, 346 were cited for serial blood pressure measurement; the rest did not meet inclusion criteria. The 66 patients with average blood pressure > 140/90 qualified for ambulatory blood pressure monitoring. Sensitivity of the serial measurement of blood pressure interpreted by any of the guidelines used was higher than 88% and specificity of less than 22%; the positive odds ratio was close to 1 in all cases. Conclusion: serial blood pressure measurement compared with ambulatory blood pressure monitoring has high sensitivity (greater than 88%) and low specificity (less than 22%) based on the three clinical guidelines used, and is not recommended as a reference test.

Efficacy of early treatment with carbamazepine in prevention of neuropathic pain in patients with spinal cord injury.

OBJECTIVE: The aim of this study was to evaluate whether early treatment with carbamazepine decreases the incidence of neuropathic pain (NP) or its intensity in patients with spinal cord injury. DESIGN: This study was a randomized, double-blind, placebo-controlled clinical trial at a third-level university hospital involving patients older than 18 yrs with a diagnosis of spinal cord injury sustained within 2 wks before enrollment and without evidence of NP. The patients received either carbamazepine up to 600 mg/day or placebo for 1 mo. Pain intensity was measured with a 10-cm visual analog scale and the SF-36 bodily pain subscale; quality-of-life, with the Short Form 36 (SF-36) Scale; and depression, with the Zung Self-Rating Depression Scale. Measurements were carried out at the start of the randomized trial and at the 1-, 3-, and 6-month follow-up assessments. RESULTS: Twenty-one of 46 patients developed NP. At the 1-, 3-, and 6-month follow-up assessments, NP was present in 4, 11, and 10 patients of the carbamazepine group and in 8, 9, and 8 patients of the placebo group, respectively. At 1 mo, two patients in the carbamazepine group vs. eight patients in the placebo group reported moderate/intense pain (visual analog scale, ≥4.0; P = 0.024). At the 3- and 6-month follow-up appointments, moderate/intense pain was reported by eight vs. six (P = 0.498) and six vs. eight patients (P = 0.298), carbamazepine and placebo group, respectively. There was no difference in the depression ratings or in any of the SF-36 scales. CONCLUSIONS: Early intervention with carbamazepine decreased NP incidence at the 1-month but not at the 3- and 6-month follow-ups in the group of patients with acquired spinal cord injury.

Gunshot wounds of abdomen: evaluation of stable patients with triple-contrast helical CT.

PURPOSE: To assess helical computed tomography (CT) with contrast material administered intravenously, orally, and rectally (triple contrast helical CT)) in the prospective evaluation of stable patients with abdominal gunshot wounds in whom there is no clinical indication for immediate exploratory laparotomy. MATERIALS AND METHODS: The study was conducted for 19 months. All patients met the following inclusion criteria: age of 16 years or older, hemodynamic stability, no clinical signs of peritoneal irritation, and signed consent to participate. Patients with obvious indications for laparotomy, such as gastrointestinal bleeding or evisceration, were excluded from the study. Forty-seven patients fulfilled the criteria and underwent abdominal triple-contrast helical CT. CT findings were evaluated by one of four radiologists for evidence of peritoneal penetration and injury to solid organs or hollow viscera. Patients were followed up clinically for 13 weeks. CT findings were compared with those at surgery and/or clinical follow-up. RESULTS: CT demonstrated abnormalities in 27 (57%) patients. Laparotomy was performed in 11 (23%) patients; 10 procedures were therapeutic and one was nontherapeutic. The remaining 20 patients had a negative CT scan. These patients were treated conservatively. One injury was missed at CT. For prediction of the need for laparotomy, sensitivity of CT was 96%; specificity, 95%; positive predictive value, 96%; negative predictive value, 95%; and accuracy, 96%. CONCLUSION: In stable patients with gunshot wounds to the abdomen in whom there is no indication for immediate surgery, triple-contrast helical CT can help reduce the number of cases of unnecessary or nontherapeutic laparotomy (negative laparotomy) and can help identify patients with injuries that may be safely treated without surgery.

Bloqueo de los nervios iliohipogástrico e ilioinguinal para analgesia posquirúrgica en cesárea tipo Pfannenstiel realizada bajo anestesia general ¿Qué concentración del anestésico local usar? / Iliohypogastric ano ilioinguinal block for postsurgical analgesia after Pfannenstiel cesarean section performeo unoer general anaesthesia

El bloqueo bilateral de los nervios Iliohipogástrico e Ilioinguinal con bupivacaína al 0.5 por ciento puede proveer analgesia luego de cesárea con incisión de Pfannenstiel aunque la cantidad de droga usada está cerca de la dosis máxima segura. Diseñamos este estudio para comparar el efecto analgésico de la bupivacaína al 0.5 por ciento y diluida al 0.25 por ciento. Se incluyeron treinta pacientes aleatoriamente asignadas a un grupo de estudio (bupivacaína 0.25 por ciento, n= 15) y uno de control (bupivacaína 0.5 por ciento, n=15). Se evaluaron las pacientes con una Escala Visual Análoga (EVA) a las O, 4, 8, 12 y 24 horas posoperatorias por médicos que no sabían a qué grupo pertenecían y sólo en caso de necesidad se prescribió analgesia IM con Diclofenaco. Los puntajes de analgesia y los requerimientos de analgesia complementaria fueron notoriamente similares en ambos grupos y no hubo diferencias estadísticamente significativas. Concluimos que el bloqueo de estos nervios es una técnica analgésica efectiva (el dolor siempre estuvo en promedio por debajo de 4 en la EVA), que no es afectada por la dilución del anestésico y que además es segura pues no se presentaron complicaciones

The Iliohypogastric and Ilioinguinal bilate. ral block with 0.5% bupivacaine can provide analgesia after Pfannenstiel cesarean section although the required amount of the drug is near the maximum secure dose. We designed this study in order to compare the analgesic effect of 0.5% bupivacaine and diluted 0.25% bupivacaine. Thirty patients were included in the study and asigned in aleatory form to either a study (0.25% bupivacaine n=15) or a control group (0.5% bupivacaine n=15). They were evaluated with the Visual Analogue Scale (VAS) at 0,4,8,12,24 postoperative hours by physicians who did not know the group of the patient and prescribed intramuscular analgesia with Dicofenac only if required. The analgesia scores and the complementery analgesia requirements were similar in both groups and there were no significative differences. We conclude that this nerve block is an effective analgesic technique (pain was always under 4 in the VAS), unaffected by the anesthetic dilution and furthermore that it is a safe technique since there were no complications derived from the procedure.