Cost-Effectiveness of Dexamethasone Intravitreal Implant in Naïve and Previously Treated Patients with Diabetic Macular Edema

PURPOSE

To compare the direct costs associated with the dexamethasone intravitreal implant (DEX-i) in treatment-naïve and previously treated eyes with diabetic macular edema (DME) in a real clinical setting.

METHODS

Retrospective and single-center study conducted in a real clinical scenario. Consecutive DME patients, either naïve or previously treated with vascular endothelial growth factor inhibitors (anti-VEGF), who received treatment with one or more DEX-i between May 2015 and December 2020, and who were followed-up for a minimum of 12 months, were included in the study. The cost analysis was performed from the perspective of the Andalusian Regional Healthcare Service. The primary effectiveness endpoint was the probability of achieving an improvement in best-corrected visual acuity (BCVA) ≥ 15 ETDRS letters after 1 year of treatment. The incremental cost-effectiveness ratio (ICER) of different improvements in BCVA was calculated.

RESULTS

Forty-nine eyes, twenty-eight (57.1%) eyes from the treatment-naïve group and twenty-one (42.9%) from the previously treated group, were included in the analysis. The total cost of one year of treatment was significantly lower in the treatment-naïve eyes than in the previously treated eyes [Hodges-Lehmann median difference: EUR 819.1; 95% confidence interval (CI): EUR 786.9 to EUR 1572.8; p < 0.0001]. The probability of achieving a BCVA improvement of ≥15 letters at month 12 was significantly greater in the treatment-naïve group than in the previously treated group (rate difference: 0.321; 95% CI: 0.066 to 0.709; p = 0.0272). The Cochran-Mantel-Haenszel Odds Ratio of achieving a BCVA improvement of ≥15 letters at month 12 was 3.55 (95% CI: 1.09 to 11.58; p = 0.0309). In terms of ICER, the treatment-naïve group showed cost savings of EUR 7704.2 and EUR 5994.2 for achieving an improvement in BCVA ≥ 15 letters at month 12 and at any of the measured time points, respectively.

CONCLUSIONS

DEX-i was found to be more cost-effective in treatment-naïve eyes than in those previously treated with anti-VEGF. Further studies are needed to determine the most cost-effective treatment based on patient profile.

[The importance of self-regulation: Analysis of the activity of the medical ethics and deontology commission in Cordoba]

OBJECTIVE

to analyse the activity of the Medical Ethics and Deontology Commission (MEDC) of the College of Physicians of Cordoba regarding conflictive situations in the profession from 2013 through 2021.

MATERIAL AND METHODS

cross-sectional observational study, in which 83 cases of complaints submitted to the College were collected.

RESULTS

the incidence was 2.6 complaints‰ members/year, with a total of 92 doctors reported. 61.4% were submitted by the patient, 92.8% of which were addressed to a single doctor. 30.1% were in the speciality of family medicine, 50.6% in the public sector and 72% in outpatient care. In 37.7% the chapter of the Code of Medical Ethics concerned was chapter IV (quality of medical care). In 89.2% of cases the parties came to make a statement, with a higher risk of disciplinary proceedings being observed when the statement was both, oral and written (OR:4.61; p=0.026). The median resolution time was 63 days, significantly longer in cases proposed for disciplinary proceedings (146 days vs. 58.50 days; OR:1.01; p=0.008). The MEDC found 15.7% (n=13) to be in breach of ethics, with 15 doctors being disciplined (16.3%) and 4 sanctioned (26.7%) with a warning and temporary suspension from practice.

CONCLUSIONS

The role of the MEDC is fundamental in the self-regulation of professional practice. Inappropriate behaviour during patient care or between colleagues has serious ethical implications, disciplinary repercussions for the physician, and it particularly undermines patients' trust in the medical profession.

Study of the Psychometric Properties of the Spanish Version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA)

BACKGROUND

The early detection of moral distress requires a validated and reliable instrument. The aim of this study was to carry out an advanced analysis of the psychometric properties of the moral distress scale for health professionals (MMD-HP-SPA) by performing a validation of the construct and its internal and external reliability.

METHODS

We performed a multicentre cross-sectional study in health professionals belonging to the Andalusian public health system. Construct validity was performed by exploratory (n = 300) and confirmatory (n = 275) factor analysis (EFA/CFA) in different subgroups; we also analysed the internal consistency and temporal reliability of the scale.

RESULTS

384 doctors and 191 nurses took part in the survey. The overall mean for moral distress was 128.5 (SD = 70.9), 95% CI [122.7-134.3], and it was higher in nurses at 140.5 (SD = 74.9) than in doctors at 122.5 (SD = 68.1), F = 8.37 p < 0.01. The EFA produced a model of five components which accounted for 54.8% of the variance of the model. The CFA achieved a goodness of fit of Chi2 = 972.4; AIC = 1144.3; RMSEA = 0.086; CFI = 0.844; TLI = 0.828; NFI = 0.785.

CONCLUSIONS

The MMD-HP-SPA scale has solid construct validity, excellent internal consistency, optimal temporal reliability, and underlying dimensions which effectively explore the causes of moral distress in health professionals, thus guaranteeing its use in hospital and community settings.

Analysis of conventional and nonconventional forensic specimens in drug-facilitated sexual assault by liquid chromatography and tandem mass spectrometry

The incidence of drug-facilitated sexual assault (DFSA) has dramatically increased in the last decades. Forensic analytical scientists continuously seek new methods and specimens to prove the incidence of intoxication for the judiciary system. Factors influencing sample selection include the ease of obtaining the samples and the window of detection of the drugs, among others. Both conventional (blood, urine) and non-conventional specimens (hair, nails, fluids) have been proposed as suitable in DFSA cases. Reported sample treatments include a variety of liquid-liquid and solid-phase extraction as well as dilute-and-shoot procedures and microextraction techniques. Regarding analysis, liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) has emerged as the preferred confirmatory technique, due to its sensitivity, selectivity, and wide-scope applicability. In this review, we critically discuss the most common specimens and sample treatments/analysis procedures (related to LC-MS/MS) that have been reported during the last ten years. As a final goal, we intend to provide a critical overview and suggest analytical recommendations for the establishment of suitable analytical strategies in DFSA cases.

The role of undergraduate medical students training in respect for patient confidentiality

BACKGROUND

Encouraging professional integrity is vital for providing a standard of excellence in quality medical care and education and in promoting a culture of respect and responsibility. The primary objective of this work consisted of studying the relationship of medical students to the right to patient privacy in Spain, specifically by analysing the conditions for accessing patient clinical histories (CHs).

METHODS

A cross-sectional study was conducted based on a questionnaire sent by e-mail to final-year students at 41 Spanish universities. It had 14 multiple choice and closed questions framed in 3 large blocks. The first question addressed basic general knowledge issues on the right to privacy and the obligation for confidentiality. The two remaining blocks were made up of questions directed towards evaluating the frequency with which certain requirements and action steps related to students attending patients were performed and regarding the guarantees associated with accessing and handling patient CHs both on paper and in the Electronic Medical Record.

RESULTS

A total of 245 valid replies were considered. A total of 67.8 % of participants were women, with an average age of 24.05 ± 3.49 years. Up to 90.6 % were aware that confidentiality affected the data in CHs, although 43.3 % possessed non-anonymized photocopies of patient clinical reports outside the healthcare context, and only 49.8 % of the students were always adequately identified. A total of 59.2 % accessed patient CHs on some occasions by using passwords belonging to healthcare professionals, 77.2 % of them did not have the patients' express consent, and 71.9 % accessed a CH that was not anonymised.

CONCLUSIONS

The role of healthcare institutions and universities is considered to be fundamental in implementing educational measures regarding the risks and ethical and legal problems arising from the use of CHs among professionals and students. A thorough study of medical ethics is needed through the analysis of clinical cases and direct exposure to situations in which the patient's confidentiality is questioned.

[Ethical issues in primary care during the coronavirus (SARS-CoV-2) pandemic]

Las emergencias de salud pública, como la que estamos viviendo con la pandemia originada por el coronavirus SARS-CoV-2, han originado trágicas limitaciones de recursos que impiden salvar vidas. Provocan tensiones en la atención sanitaria centrada en el paciente como eje del sistema en condiciones normales, y en la misma atención sanitaria en situaciones de emergencia originadas en la COVID-19. En esta revisión abordamos algunos de los problemas asistenciales, organizativos y éticos que este escenario ha provocado en la atención primaria, como: cancelación de actividades programadas; escasa atención domiciliaria y seguimiento de pacientes ancianos, enfermos crónicos e inmovilizados; desabastecimiento de EPI y exposición al riesgo de los profesionales sanitarios, y finalmente los problemas asociados a la telemedicina y a la atención telefónica a los pacientes.

Intravitreal dexamethasone implant in naïve and previously treated patients with diabetic macular edema: a retrospective study

AIM

To assess the effect of the intravitreal dexamethasone implant (DEX) Ozurdex on the best corrected visual acuity (BCVA) and central retinal thickness (CRT) in patients with diabetic macular edema (DME).

METHODS

Totally 43 eyes (24 naïve and 19 previously treated) were included in the study. Retrospective and single-center study involved patients with a clinical diagnosed of DME, who received treatment with DEX implant and had a follow-up of at least 12mo. Primary endpoints included changes in BCVA and CRT.

RESULTS

At month 12, mean improvement in BCVA from baseline was 20.4±20.8 letters and 6.8±6.9 letters in naïve and previously treated patients, respectively (P=0.0132). The naïve patients achieved the BCVA improvement significantly faster (2.4±1.5mo) than the previously treated ones (3.5±2.4mo, P=0.0298; Mann-Whitney test). The proportion of eyes gaining ≥15 letters was 54.2% and 21.1% in the non-previously treated and previously treated groups, respectively (P=0.0293). CRT was significantly reduced from 484.0±119.8 and 487.5±159.9 µm to 272.0±39.2 and 233.5±65.7 µm in the naïve and previously treated patients, respectively; P<0.0001 each, respectively. The presence of subretinal fluid was significantly associated with the proportion of patients achieving a BCVA improvement ≥5 letters [HR (95%CI), 1.23 (1.04 to 1.45), P=0.0145]; ≥10 letters [HR (95%CI), 1.75 (1.10 to 2.77), P=0.0182]; and ≥15 letters [HR (95% CI), 2.04 (1.03 to 4.02), P=0.0407]. Naïve patients received less DEX implants throughout the study than the previously treated ones (1.8±0.6 vs 2.3±0.6, P=0.0172, respectively). Totally 9 patients (20.9%) have developed ocular hypertension, which was successfully controlled with topical hypotensive drugs. Of the 23 phakic eyes at baseline, 5 eyes (21.7%) either had new onset lens opacity or progression of an existing opacity during the study follow-up. Four of them (2 in the naïve group and 2 in the previously treated one) required cataract surgery at months 4, 6, 6, and 6, respectively.

CONCLUSION

The results obtained in this study may support the early use of DEX Ozurdex as first line therapy in naïve patients.

Structural abnormalities in the human diaphragm in drowning and hanging deaths: preliminary results

PURPOSE

Previous experiments in rats have indicated that there are histological changes in skeletal muscle in drowning deaths; these changes include muscle fibers that contain ragged red fibers (RRF). The purpose of this study was to examine whether these changes also occur in humans.

METHODS

Histologic and histochemical examinations of three muscles (diaphragm, pectoralis, and psoas) were performed on 24 cadavers with three different causes of death: 8 drowning, 8 hanging, and 8 sudden cardiac disease. Muscle samples were stained with hematoxylin-eosin, MGT, nicotinamide adenine dinucleotide-tetrazolium reductase, succinate dehydrogenase, ATPase, and acid phosphatase via standard staining procedures.

RESULTS

There were statistically significant differences in the detection of RRFs in these cohorts. Additionally, several other cytoarchitectural changes (whorled and core-like fibers) were observed in the diaphragm in the drowning cohort and to a lesser extent in the hangings. These structural abnormalities were not observed in the sudden cardiac disease deaths, thus suggesting a common mechanism for the production of these muscular changes that is not shared in the cardiac death group. The mechanism is most likely intense hypoxia and mechanical trauma of the respiratory muscles in the setting of active blood circulation with intense muscle contraction.

CONCLUSIONS

Our results confirmed that there are histological changes in the diaphragm in drownings and, to a lesser extent, in hangings.

Use of XRD and SEM/EDX to predict age and sex from fire-affected dental remains

In fire scenarios, the application and accuracy of traditional odontological methods are often limited. Crystalline studies and elemental profiling have been evaluated for their applicability in determining biological profiles (age and sex) from human dentition, particularly fire- and heat-affected dental remains. Thirty-seven teeth were paired according to tooth type and donor age/sex for the analysis of crown and root surfaces pre- and post-incineration using X-ray diffraction (XRD) and scanning electron microscopy (SEM/EDX). In unburned crowns, carbon (C) content showed a positive correlation with age, whereas phosphorus (P) and calcium (Ca) contents showed a negative correlation with age. In unburned roots, C, P and Ca contents also showed significant changes that were opposite of those observed in the crowns. In relation to sex, females exhibited a higher C ratio than males, whereas males showed significantly higher levels of oxygen (O), P and Ca in unburned roots. Incineration resulted in an increase in the crystallite size that correlated with increasing temperature. No differences in hydroxyapatite (HA) crystallite size were found between age groups; however, unburned teeth from females exhibited a larger crystallite size than did those from males. The challenges of using XRD with a 3D sample were overcome to allow analysis of whole teeth in a nondestructive manner. Further studies may be useful in helping predict the temperature of a fire.

Manner of Death for In-Custody Fatalities

In-custody deaths are typically investigated by a medical examiner or coroner (ME/C) and include those that occur while in the custody of the police or in a government detention facility (e.g., prison). The potential manners of death are natural, homicide, suicide, accident, therapeutic complication, and undetermined. Once the cause of death is determined, the manner of death is certified based upon the cause and the circumstances of death. Deaths in custody may be challenging due to the potential for death at the hand of another (e.g., inmate, corrections officer, or law enforcement agent) or due to neglect. When a government takes a person's liberty, they have a duty to ensure safe and adequate housing, food, and medical care. Failure of a responsible party to exercise proper care of a person in-custody, may affect the manner of death. Since in-custody deaths at the hand of a government agent can be challenging to certify, we will focus on these manners of death including those associated with excited delirium (ED). Although manners are easily and consistently applied in most deaths, there are nuances in some instances which may result in jurisdictional variations in the determination of the manner of death. We will discuss these variations as the determination made by the ME/C is an opinion based upon his/her particular training, experience, and judgment.

Influence of antiretroviral treatment on quality of life in seropositive inmates

The aim of the study is to evaluate the influence of antiretroviral treatment on health-related quality of life (HRQOL) of three groups of HIV-positive inmates: those who are taking antiretroviral treatment, those who are not on treatment as it has not yet been indicated, and those who refuse to take treatment even though it has been recommended. A cross-sectional study was conducted on 585 HIV+ inmates in three prisons. The response variable was HRQOL. Independent variables were: sociodemographic variables, psychosocial and drug-related variables. Two multivariate linear regression models were constructed in order to determine the HRQOL, physical health score (PHS) and mental health score (MHS), for each of the three groups identified, using patients who refused treatment as the reference category. Patients who refused therapy had a lower MHS compared with patients in whom treatment was not indicated (P = 0.038). With regard to PHS, patients refusing therapy had a lower score than patients who were not indicated therapy (P = 0.005), and than patients receiving therapy (P = 0.010).

[Patients who refuse antiretroviral treatment in prison]

INTRODUCTION

Current studies of HIV+ patients in the prison population have been carried out without considering differences that might exist between patients who accept retroviral treatment and those who do not. One possible reason for this may be the difficulty in gaining access to patients who refuse antiretroviral treatment. However, the prison environment makes it possible to locate and study this type of patient, who up till now has not been the subject of study. The aim of this article is to describe the clinical and psychosocial state of HIV+ inmates who refuse ARVT and compare this data with patients receiving treatment and others for whom treatment has not been indicated.

METHODS

Cross-sectional study using 585 HIV+ inmates in three prisons in Andalusia from May to June 2004. Refusal, acceptance and non-indication of ARVT treatment was the grouping variable used. The independent variables were socio-demographic, psychosocial, clinical and other variables relating to the prison environment.

RESULTS

16.8% of patients refused ARVT, while 56.3% were receiving treatment and another 26.8 were not indicated for any medication. Amongst the patients that refused ARVT there was a greater prevalence of HIV co-infection, higher inprison consumption of opiates and methadone treatment, more cases pending and higher rates of recidivism.

CONCLUSIONS

these results highlight the existence of a group with unique characteristics that is accessible thanks to the special conditions within the prison environment. It is a group that chooses not to follow therapeutic indications and which represents a risk factor not only for its own health, but also for the community at large.