Rehabilitación domiciliaria postartroplastia total de rodilla: estudio coste-efectividad / Home-based rehabilitation after total knee arthroplasty: A cost-effectiveness study

Introducción: La rehabilitación domiciliaria permite a los pacientes intervenidos de artroplastia total de rodilla (ATR) volver antes a su domicilio y acelerar su reinserción comunitaria. Material y métodos: Estudio observacional simple, con incorporación consecutiva de pacientes desde noviembre del 2005 hasta mayo del 2008. Población de estudio: Pacientes remitidos al servicio domiciliario desde el Hospital Clínico de Barcelona post-ATR por gonartrosis. Intervención: Se realizó un programa de rehabilitación domiciliaria con evaluaciones antes del tratamiento y al alta, y seguimiento a los 6 meses. Se consideraron como variables de eficacia la variación en las puntuaciones del Western Ontario and McMaster Osteoarthritis (cuestionario WOMAC), el índice de Barthel (IB) y el balance articular. Se realizó una comparativa de costes según parámetros del Servei Català de la Salut. Se utilizó el test no paramétrico de Wilcoxon para comparar las puntuaciones del cuestionario WOMAC. Los datos cuantitativos fueron analizados por la t de Student. Resultados: Se reclutó a un total de 530 pacientes. El 78% de estos alcanzaron un grado de independencia con puntuación 100 según el IB, el arco de movimiento de flexión de rodilla fue superior a 100° en el 96,4% y la puntación media en todos los pacientes del cuestionario WOMAC fue de 13,48 (intervalo de confianza, 12,27-14,68). Se redujo la estancia media hospitalaria a 5,1 días, siendo el coste en el ámbito domiciliario la mitad que en el ambulatorio. Conclusión: La rehabilitación domiciliaria consigue disminuir la estancia hospitalaria con resultados funcionales óptimos y minimización de costes (AU)

Introduction: Home rehabilitation allows an earlier return to home in patients undergoing total knee arthroplasty. Material and methods: We performed a simple observational study with consecutive enrolment of patients from November 2005 to May 2008. Study population: Adult patients referred to the home-based rehabilitation service of Hospital Clinic in Barcelona after total knee arthroplasty for gonarthrosis. Intervention: We conducted a multidisciplinary home-based rehabilitation program with assessments before treatment, at discharge from rehabilitation and at 6 months follow-up. The outcomes measured were the Western Ontario and McMaster Universities Index (WOMAC), the Barthel Index (BI), and range of motion (ROM) scores. Costs were compared using parameters of the Catalan Health Service. Wilcoxon’s non-parametric test was used to analyze WOMAC outcomes. Quantitative data were analyzed using Student’s t test. Results: A total of 530 patients were recruited. Of these, 78% achieved a degree of independence, with a BI score of 100. The ROM for knee flexion was greater than 100◦ in 96.4% and the average rating of all the patients in the questionnaire WOMAC was 13.48 (CI: 12.27-14.68). The average length of hospital stay was reduced to 5.1 days, and the cost of home rehabilitation was half that in the outpatient setting. Conclusion: The home rehabilitation model reduces length of hospital stay and cost and has optimal functional results (AU)

[Utilization of generic drugs in Spain and Catalonia: possibilities of savings]. / Implantación de medicamentos genéricos (EFG) en España y Cataluña: posibilidades de ahorro.

OBJECTIVES: To analyze the degree of utilization of generic drugs in Spain and Catalonia. To determine real savings and scope for further savings due to the use of generic drugs. DESIGN: Descriptive, crossover study. SETTING: Public health prescription in Spain and Catalonia in June of 1999 and in Catalonia from January to June of 1999. MEASUREMENTS AND MAIN RESULTS: In June of 1999, the market share of generic drugs in Spain was 1.15% in units and 0.91% in pesetas of the hole drug prescription. The most used were oral ranitidine, oral diclofenac and oral amoxicillin. Catalonia, in this period, has a greater relative utilization of generic drugs, specially in psychotherapeutic agents like alprazolam and fluoxetine. During the first semester of 1999 only in 9.9% of the occasions where generic drugs could be used, were they actually prescribed. Specifically, the drug most used in its generic form was oral diclofenac with 27.1% of the all possible prescriptions. The real savings generated by the generic drugs were 0.2% of the public pharmaceutical bill, and the theoretical capacity of savings with the current generic offer were 2.3%. CONCLUSIONS: There is a low but fast-rising utilization of generic drugs in Spain and Catalonia. Nevertheless the possibilities of savings are at the moment, in relative terms, small. A greater use of them and specially a diversification of the offer is necessary to achieve important relative savings in the overall pharmaceutical bill.

Implantación de medicamentos genéricos (EFG) en España y Cataluña: posibilidades de ahorro / Utilization of generic drugs in spain and catalonia: possibilities of savings

Objetivo. Estudiar el grado de implantación de las especialidades EFG en España y Cataluña. Conocer el ahorro generado y teóricamente generable a partir de la oferta de EFG disponibles. Diseño. Estudio descriptivo, transversal. Emplazamiento. Prescripción por receta de la Seguridad Social en España y Cataluña en junio de 1999 y en enero-junio de 1999 para Cataluña. Mediciones y resultados principales. En junio de 1999, la participación de las EFG en España fue el 1,15 por ciento en envases y un 0,91 por ciento en importe sobre el total de la prescripción. Las EFG más prescritas fueron ranitidina oral, diclofenaco oral y amoxicilina oral. En ese período Cataluña presenta una utilización relativa de EFG mayor, especialmente en psicofármacos como alprazolam y fluoxetina. Durante el período enero-junio de 1999, de las prescripciones realizables como EFG en Cataluña tan sólo un 9,9 por ciento fue prescrito como tal. En concreto, el principio activo más prescrito como EFG fue el diclofenaco oral, con un 27,1 por ciento de las prescripciones. El ahorro generado por las EFG fue sólo de un 0,2 por ciento y la capacidad de ahorro teórica no utilizada (al no prescribir un EFG en lugar de una especialidad de marca) fue del 2,3 por ciento sobre el importe PVP del total de la prescripción. Conclusiones. La implantación de los genéricos en España y Cataluña es baja, pero está incrementándose con rapidez. Sin embargo, la capacidad de ahorro es actualmente todavía baja respecto al gasto total. Se precisa una mayor utilización y especialmente una mayor diversificación de la oferta EFG para conseguir un impacto relativo importante sobre la factura farmacéutica (AU)

Comparison of ultradian and circadian oscillations of carbon dioxide production by various endotherms.

Carbon dioxide emission (VCO2) was computed every 20 min from continuous CO2 concentration recordings taken during 3-30 consecutive days, in strictly controlled environmental conditions, in 54 OF1 mice, 99 Japanese quail, 66 Sprague-Dawley rats, 50 Hartley guinea pigs, 7 chicks, for 7-15 days on 2 Cynomolgus monkeys, and for 24 h on 7 premature infants. This VCO2 shows circadian and ultradian oscillations that were analyzed for frequencies and amplitudes in light-dark 12-h alternation (LD 12:12), continuous light (LL), and continuous dark (DD). Circadians were not always identified or were often masked in LL or DD (mostly in guinea pigs, quail, and rats), while ultradians (tau > or = 40 min) were found in all species, at every time, and in all light regimens. Analysis of variance and chi 2 show significant (P < 0.001) interspecies differences for ultradian (1.07 < tau < 1.40 h) intervals and for circadian and ultradian VCO2 amplitudes. Relationships between ultradian and circadian VCO2 oscillations differ according to the species, ultradians appearing as an entity characteristic for each endotherm species.

Rats grouping and the circadian and ultradian synchronization of their carbon dioxide emission by a light-dark 12:12 h alternation.

Carbon dioxide emission (VCO2) was continuously recorded during 19 consecutive days in 25 Sprague Dawley young male rats placed in the same "respiratory chamber", grouped by 5 (G) and then separated (S). All rats were in controlled environmental conditions (20 degrees C temperature, humidity, ventilation, food and water ad libitum) and submitted to a light (100 lux)-dark alternation (LD 12:12). The curves obtained with the respiratory chamber CO2 concentration sampled every 20 minutes were analyzed for circadian periods, amplitudes, phases, ultradian peak oscillation intervals and amplitudes, and VCO2 time variations at L-->D and D-->L light transitions. Analysis of variance and t test show circadian amplitudes significantly (P < 0.001) higher (by 40.9%) than in S; moreover, ultradian peak amplitudes were higher in G than in S (by 78.0% in L and 105.8% in D). The circadian and ultradian (tau > 40 min) period intervals were not significantly different in G and in S. Circadian phase differences between L-->D and D-->L were significantly greater in S (by 50.3 min) but not in G. Light transitions did not significantly modify ultradian phases in G and in S. This data shows a better LD 12:12 synchronization in G than in S, resulting mostly from an increased respiratory amplitude modulation due to interindividual interactions.

Ultradian and circadian compartmentalization of respiratory and metabolic exchanges in small laboratory vertebrates.

Carbon dioxide emission (VCO2) taken as an index of respiratory and metabolic exchanges, was continuously recorded during 4-30 consecutive days in 100 quail, 87 chicks, 347 rats, 665 mice and 70 guinea-pigs which were under controlled environmental parameters. Harmonic analysis, fast Fourier transform, chi-square periodograms, peak and trough intervals were computed with VCO2 values obtained with CO2 concentrations sampled every 20 min on the CO2 recordings. In LD 12:12 alternation, circadian rhythms were observed in all quail, chicks, rats and mice, but only in 80% of the guinea-pigs. Ultradian VCO2 rhythms, with periods which show statistically significant interspecies differences, were assessed. For each of the 5 species these computed periods, which were the same in LL and DD, were: 1.17 h for quail and chickens, 1.25 h for rats, 1.50 h for mice and 1.0 h for guinea-pigs. In LD 12:12 these periods were different during L and D in quail, chicks, rats and mice, but not in guinea-pigs. The amplitudes of these ultradian variations were, according to the species, 10-20% of their mean VCO2 levels. These ultradian rhythms persist in the absence (or masking) of circadian rhythms, e.g. in LD 12:12 in 20% of guinea-pigs and in LL in 87% of Japanese quail and in 23% of Sprague-Dawley rats. Moreover, these ultradian rhythms persist during starvation, locomotor activity restraint and ageing. These ultradian VCO2 cycles which are related to rest-activity variations appear to be basic physiological rhythms with a genetic origin.

Societal synchronization in groups of rats or quail submitted to various lighting regimens.

Groups of rats or of quail that had been previously synchronized in a light (L = 100 lux) dark (D) phase opposition (PO = LD and DL) were placed together in a L12:D12 or D12:L12 alternation or in continuous light (LL) or continuous darkness (DD). Emission of carbon dioxide (VCO2) which was continuously recorded in groups of individuals placed in respiratory chambers under controlled environmental conditions allows an index of their overall respiratory and metabolic exchanges to be found. In PO animals placed in LD or DL, the VCO2 circadian light dark synchronization comes back less quickly in rats than in quail, and the VCO2 variations at the light dark transitions (L-D and D-L) remain unchanged in rats, but are modified in quail. When PO animals are placed for 18 days in LL or DD, respiratory circadian rhythms disappear except in the grouped rats where they reappear after 4-5 days in DD.

Ultradian and circadian CO2 emission variations in nocturnal and diurnal animals exposed to a light stimulus.

1. Carbon dioxide emission (VCO2) has been continuously recorded in three laboratory animal species (Sprague-Dawley rats, Japanese quail, Hartley guinea-pigs) which differ by their nocturnal and diurnal activities. A 100 lux stimulus has been delivered at various time intervals. 2. A regular alternation of 12, 3 or 1.5 hr light (L) and darkness (D) gives VCO2 circadian and ultradian rhythms of 24, 6 or 3 hr periods, respectively, in quail and rats. 3. Such circadian and ultradian LD rhythms are not induced in all guinea-pigs. 4. The amplitudes of the VCO2 responses are greatest at D----L when the animals have a maximum diurnal activity and at L----D when their maximum activity is nocturnal. 5. Interactions between circadian and ultradian rhythms are seen in all LD experiments, as well as in continuous light (LL) or continuous dark (DD). 6. No more well-marked or even inverted VCO2 responses to the light stimuli may occur after several days of exposure to these LD alternations.

Sexual phenotype of avian chimeric gonads with germinal and stromal cells of opposite genetic sexes.

The respective roles of germinal and stromal cells in determining the sexual phenotype of the gonad were analyzed in chimeric gonads obtained by surgical recombination between young avian blastodiscs in ovo. Equivalent territories were exchanged between two blastodisc, in order that the germinal crescent and the gonad territory had a different origin (fig. 3). Embryos used for these experiments carried a sex linked pigment mutation, that made it possible to diagnose the genetic sexes of germ cells and stroma at the time when the gonad was retrieved for examination. On the basis of species, three types of combination were performed: chick germ cells in chick or quail stroma, quail germ cells in chick stroma. In each chimera, the genetic sexes of the two gonadal cell populations could be identical or opposite. However it appeared that the germ cell population was not always homogeneous. In some grafting schemes, ectopic germ cells, located outside the germinal crescent, contributed to the colonization of the experimental gonad. These germ cells were from the same territory as the stroma element of the gonad, i.e., they were of the same species and the same genetic sex. Whatever the case, in 87 chimeras that were studied, the sex phenotype of the gonads always corresponded to the genetic sex of the stroma. Thus the genetic sex of germ cells has no role in the sexual differentiation of the gonadal rudiments.

Periodic analysis of ultradian (40 min less than tau less than 24h) respiratory variations in laboratory vertebrates of various circadian activities.

Continuous recordings of respiratory gas exchanges of various laboratory endotherm vertebrate species, which have either a nocturnal (mouse, rat) or diurnal (monkey, quail, chicken) or equivocal (guinea-pig) maximal activity, kept under controlled environmental conditions of temperature, humidity, ventilation and provided with food and water ad libitum, show ultradian oscillations of mean and low frequencies (1 less than f less than 35 c.day-1). Harmonic analysis was used to assess periodic or random ultradian variations and to compute amplitudes and phases of these oscillations when these vertebrates were submitted to a light (100 lx) and dark circadian alteration (LD 12:12). Spectral analysis shows that a 100-lx continuous illumination or continuous darkness decreases circadian respiratory rhythms and increases these ultradian respiratory oscillations.

Biological parameters in Japanese quail genetically selected for resistance or sensitivity to an acute hypoxic survival.

Various biological parameters were measured in two strains of Japanese quail selected for their resistance (Ls+) or susceptibility (Ls-) to an acute normobaric hypoxic challenge. Adults of these two strains showed very little or no significant differences concerning body weights, carbon dioxide emission, photoperiodic (L----D and D----L) respiratory reactions, cloacal temperatures, heart rates and ECG QRSII amplitudes, red blood cell data, hemoglobin electrophoresis, and plasma corticosterone (before and after an hypoxic challenge). Enzymatic capacities of phosphofructo-and pyruvate kinases, of glucose-6-phosphatase, lactico- and malate-dehydrogenases, measured in brains and hearts, showed but few statistically significant differences. Changing societal contacts did not suppress the differences of acute hypoxic survival between the two strains. Several statistically significant differences which concern reproduction and eggs, and especially egg laying and egg water vapor conductance were noted between the two strains.

Ultradian and circadian respiratory rhythms in grouped small laboratory vertebrate species as a method to assess the effects of environmental challenges.

The recording over several days of the respiratory gases of groups of different laboratory vertebrates (mice, rats, quails), placed in a chamber with controlled ventilation, and in standardized environmental conditions of temperature, humidity, light, noise and feeding, shows ultradian (tau less than 24 hr) and circadian (tau congruent to 24 hr) rhythms. A simple variance analysis method shows periodic carbon dioxide changes, due to different environmental stimuli. Societal, light, acoustical, carbon monoxide and starvation challenges are given as examples. This technique enables us quickly to collect, on a great number of animals, data which correspond to societal behavior changes peculiar to the considered species.

Evidence of genetic differences in acute hypoxia survival.

In a population of Japanese quail, a genetic selection was performed leading to two strains--one resistant and one susceptible to an acute hypoxic nitrogen challenge as well as to an acute carbon monoxide intoxication. Crossing these two strains gives an F1 hybrid whose survival to acute hypoxia appears to be very close to the susceptible strain. The difference in acute hypoxic survival already appears in embryos at the age of 12 d. Susceptibility to acute hypoxia seems to be a dominant character.

[Histogenetic study and mixed lymphocyte reaction in 2 lines of chickens homozygotic for haplotypes B14 and B19]. / Etude histogénétique et réaction lymphocytaire mixte chez deux lignées de poulets homozygotes pour les haplotypes B14 et B19.

The histocompatibility status of homozygous chicken for B14 and B19 haplotypes of Hy-line stock origin was compared by skin grafts and the mixed lymphocyte reaction. No differences in graft survival (33 days) could be recorded in H-B compatible grafts in either haplotype tested. Reciprocal allografts however (B14 in equilibrium B19) were rejected within 12 days in both haplotypes. A weak stimulation index (1.3-1.9) persisted in individuals serologically identical with respect to the H-B complex whereas a strong index of 10.4 was obtained in allogeneic lymphocyte cocultures.

Harmonic analysis of ultradian respiratory rhythms in four small laboratory vertebrates lit in LD12:12.

Fourier harmonic analysis has been applied to 20-min samples of VCO2, recorded every 12 sec over several (7-12) days, in one mouse, one rat, one guinea-pig, or one quail, maintained in controlled conditions of temperature, humidity and ventilation, and lit in LD12:12 (100 lux). The harmonic computations, during L and D of ultradian periods (1.2 hr less than tau less than 12 hr) evidence statistically significant differences in amplitude and phase between these four small laboratory species. These periodic respiratory differences correspond to discrepancies in their diurnal and nocturnal activities, and in their responses to light and dark.

Inter and intraspecies genetic differences in survival to an acute carbon monoxide challenge in mice, rats, guinea-pigs, quails and chickens.

1. Groups of small laboratory vertebrates, of both sexes, have been submitted to an acute carbon monoxide challenge, close to a LD50. 2. An interspecific classification, from low to high CO sensitivity, gives: guinea-pigs-mice-chicks-rats-quails. 3. Interstrain statistical differences were observed in all species, with the exception of guinea-pigs. Furthermore, among two selected genotypes of Japanese quails, one was resistant to acute nitrogen hypoxia and to carbon monoxide intoxication and the other sensitive to both these types of hypoxia. 4. Interspecific comparisons show similarities of genetic differences to acute CO intoxication and acute nitrogen normobaric hypoxia.