Effect of Air Pollution on the Basal DNA Damage of Mother-Newborn Couples of México City

Environmental pollution of megacities can cause early biological damage such as DNA strand breaks and micronuclei formation. Comet assay tail length (TL) reflects exposure in the uterus to high levels of air pollution, primarily ozone and air particles (PM10), including mothers' smoking habits during pregnancy, conditions which can lead to low birth weight. In this biomonitoring study, we evaluated basal DNA damage in the cord blood cells of newborn children from Mexico City. We found a correlation between DNA damage in mothers and their newborns, including various parameters of environmental exposure and complications during pregnancy, particularly respiratory difficulties, malformations, obstetric trauma, neuropathies, and nutritional deficiencies. Mothers living in the southern part of the city showed double DNA damage compared to those living in the northern part (TL 8.64 μm vs. 4.18 μm, p < 0.05). Additionally, mothers' DNA damage correlates with exposure to NOx (range 0.77-1.52 ppm) and PM10 (range 58.32-75.89 μg/m3), as well maternal age >29. These results highlight the sensitivity of the comet assay in identifying differential in utero exposure for newborns whose mothers were exposed during pregnancy. They also suggest the importance of antioxidants during pregnancy and the role of the placental barrier in protecting the newborn from the DNA-damaging effects of oxidative pollution.

Effect of fresh frozen plasma on the in vitro activation of U937 monocytes: a potential role for the age of blood donors and their underlying cytokine profile

BACKGROUND

Fresh frozen plasma (FFP) administration may increase the risk of nosocomial infections in parallel with the development of immune modulation. This could be driven by soluble mediators, possibly influencing the in vitro activation of human U937 monocyte cells, in a manner dependent on the age of the donors.

METHODS

FFP donors were stratified into groups of 19-30 years, 31-40 years or 41-50 years, and U937 cells were cultured with FFP (alone or plus lipopolysaccharide-LPS) for 24 h. Both in FFP and supernatants, TNF, IL-1β, IL-6, and IL-10 levels were measured by ELISA. Additionally, CD11B, TLR2, and CASP3 gene expression were measured by qtPCR in U937 cells. Total phagocytic activity was also assayed.

RESULTS

Elevated IL-10, but low TNF and IL-1β levels were measured in FFP from individuals aged 19-40 years, whereas in individuals aged 41-50 years FFP were characterized by equalized TNF and IL-10 levels. Elevated IL-6 levels were found in all FFP samples, especially in those from the oldest individuals. FFP stimulation was associated with striking modifications in cytokine production in an age-dependent way. Exposure to FFP attenuates the response to LPS. TLR2 and CD11B expression were enhanced regardless of the age of plasma donors, although CASP3 expression was increased only when FFP from individuals aged 19-40 years were tested. Phagocytosis decreased after exposure to FFP regardless of donor age.

CONCLUSION

Our results suggest that soluble mediators in FFP may modulate the functioning of monocytes. Interestingly, this effect appears to be partially influenced by the age of donors.

Lack of association between genotypes and haematogenous seeding infections in a large cohort of patients with methicillin-resistant Staphylococcus aureus bacteraemia from 21 Spanish hospitals

There is increasing concern regarding the association between certain methicillin-resistant Staphylococcus aureus (MRSA) genotypes and poor clinical outcome. To assess this issue, a large cohort of 579 subjects with MRSA bacteraemia was prospectively followed from June 2008 to December 2009, in 21 hospitals in Spain. Epidemiology, clinical data, therapy, and outcome were recorded. All MRSA strains were analysed in a central laboratory. Presence of a haematogenous seeding infection was the dependent variable in an adjusted logistic regression model. Of the 579 patients included in the study, 84 (15%) had haematogenous seeding infections. Microdilution vancomycin median MIC (IQR) was 0.73 (0.38-3) mg/L. Most MRSA isolates (n = 371; 67%) belonged to Clonal Complex 5 (CC5) and carried an SCCmec element type IV and agr type 2. Isolates belonging to ST8-agr1-SCCmecIV, ST22-agr1-SCCmecIV and ST228-agr2-SCCmecI--a single locus variant of ST5--accounted for 8%, 9% and 9% of the isolates, respectively. After adjusting by clinical variables, any of the clones was associated with increased risk of haematogenous seeding infections. Higher vancomycin MIC was not identified as an independent risk factor, either. In contrast, persistent bacteraemia (OR 4.2; 2.3-7.8) and non-nosocomial acquisition (3.0; 1.7-5.6) were associated with increased risk.

Effectiveness of interventions to promote physical activity among socioeconomically disadvantaged women: a systematic review and meta-analysis

Physical activity is important for preventing weight gain and obesity, but women experiencing socioeconomic disadvantage are at high risk of inactivity. This study aimed to determine the effectiveness of interventions to increase physical activity among women experiencing disadvantage, and the intervention factors (i.e. physical activity measure, delivery mode, delivery channel, setting, duration, use of theory, behavioural techniques, participant age, risk of bias) associated with effectiveness. We conducted a meta-analysis of controlled trials using random-effects models and meta-regression. Seven databases were searched for trials among healthy women (18-64 years), which included a physical activity intervention, any control group, and statistical analyses of a physical activity outcome at baseline and post-intervention. Nineteen studies were included (n = 6,339). Because of substantial statistical heterogeneity (χ(2) = 53.61, df = 18, P < 0.0001, I(2) = 66%), an overall pooled effect is not reported. In subgroup analyses, between-group differences were evident for delivery mode, which modestly reduced heterogeneity (to 54%). Studies with a group delivery component had a standardized mean difference of 0.38 greater than either individual or community-based delivery. Programs with a group delivery mode significantly increase physical activity among women experiencing disadvantage, and group delivery should be considered an essential element of physical activity promotion programs targeting this population group.

9 CAN ONE PREDICT THE RESISTANCE OF BULL SPERM TO CRYOPRESERVATION BY ANALYZING MOTILITY PARAMETERS BEFORE FREEZING?

Batches of straws often need to be thrown away after freezing due to a too-few-number of motile or progressive sperm cells (spz), whereas the quality of the fresh sperm was considered as acceptable. Our objective was to evaluate whether variables related to velocity or linearity for fresh spz could help to predict the resistance to freezing and allow the discard of poor-quality batches before freezing. Motility traits of 20 ejaculates from 20 Belgian Blue bulls collected at an AI center were evaluated for motile spz both before and after freezing using Computer-Assisted Sperm Analysis (CASA, Spermvision; Minit�b, Tiefenbach, Germany). Only six traits of motility showed a normal distribution in the population of motile spz and were kept for further analysis together with the proportion of motile (%mot) and progressive (%prog) spz: velocity on the curved line (VCL), velocity on the straight line (VSL), velocity on the average path (VAP), linearity (LIN = VSL/VCL), beat cross frequency (BCF), and average orientation change of the head (AOC). Significant variation between bulls was observed both before and after freezing for all of the analyzed traits (ANOVA2; P &lt; 0.001). Moreover, freezing significantly altered the motility measures (ANOVA2; P &lt; 0.001). For each variable, a significant correlation was observed between the values (mean or percentage) obtained for each bull before and after freezing (Pearson coefficient: R = 0.43 to 0.72; P &lt; 0.05). However, the impact of freezing on the quality of motility differed between bulls, with low impact for some bulls and major impact for others. Three motility traits measured before freezing were highly correlated with %mot or %prog after freezing: VAP, VSL, and %prog (R = 0.75 to 0.82; P &lt; 0.001). When we evaluated the prediction of rejection or acceptance of a batch of straws after freezing (based on a threshold of 15% progressive spz) by using motility measures recorded before freezing, five traits allowed us to discriminate low-quality batches: %mot, %prog, VAP, VSL, and LIN. Applying to fresh sperm a threshold of 92 �m s-1 for VAP or 84 �m s-1 for VSL allowed us to predict, respectively, 6 and 7 out of the 9 batches that would be rejected after freezing, without discarding batches of acceptable quality. Moreover, using the %mot or %prog before freezing caused us to discard only 3 and 4 batches, respectively. Combining different traits did not add to the precision. In conclusion, analysis of velocity traits for fresh sperm seems more efficient than analysis of %mot or %prog to discard batches that will be of poor quality after freezing. Such analysis could prevent useless work and expense related to straw filling and freezing. However, the definition of thresholds needs further analysis with a larger number of batches of semen and will vary from one AI center to another, depending, for example, on the breed characteristics, the number of spz per straw, the CASA system, or the freezing procedure. This work was supported by the programme FIRST Objective 3 of the European Commission and the Ministery of the R�gion wallonne de Belgique.

[Treatment of Tourette syndrome and its comorbidity: experience with 17 cases]

INTRODUCTION

Clinical characteristics and comorbid disorders of Tourette syndrome (TS) are reviewed along with a presentation of our experience with 17 cases.

MATERIAL AND METHODS

We carried out a retrospective study of pediatric patients with TS admitted from 1998 to 2004 in Fundación Hospital Alcorcón.

RESULTS

Seventeen patients were obtained, 16 of whom were men and there was only 1 woman. Present age ranged from 7 to 17 years old. Most frequent comorbid disorders were attention deficit disorder (ADD) in 9 patients, (53%), obsessive-compulsive disorder in 8 (48%) and anxiety in 7 (41%). Learning disorders were found in 7 patients (41%), 5 of whom have concurrent ADD and 1 severe obsessive compulsive disorder. Psychopharmacological treatment was withdrew in the 2 cases treated with halloperidol due to the presence of severe extrapyramidal symptoms (EPS) and in 3 of the 7 cases treated with pimozide (one of them was withdrawn due to EPS). No EPS was found with atypical neuroleptics, but sedation and weight gain was common. Methylphenidate was administered to 7 patients without an increase in tics.

CONCLUSIONS

In our sample the most common comorbid disorders were ADD, obsessive-compulsive disorders, anxiety and learning disorders. Atypical neuroleptics were better tolerated than classic ones, although the incidence of side effects is elevated. Methylphenidate was not associated with tic worsening.

93COMPUTER-ASSISTED ANALYSIS OF BOVINE SPERM MOTILITY BEFORE AND AFTER CRYOPRESERVATION

Sperm cryopreservation causes various types of damage, including membrane injury, oxidative stress, and loss of the acrosome. In cattle, the mortality rate after sperm cryopreservation reaches roughly 50%, and surviving sperm cells have a lower motility and lower fertility than their fresh counterparts. Large variations are also observed between bulls. The aim of this study was to analyse different motility parameters before and after freezing in order to establish correlations. The final objective is to determine, before freezing, parameters that could predict the characteristics of motility after freezing. A computer-assisted sperm analyser (Hobson Sperm Tracker) was used. We analyzed one ejaculate from 30 different bulls before and after freezing (minimum 300 spermatozoa/analysis). Reliable parameters (&lt;10% variation for the same ejaculate) were then selected and included VCL (curvilinear velocity), VAP (average path velocity), MAD (mean angular head displacement), ALH (amplitude of lateral head displacement), STR (straightness of path), and the percentage of motility (%Mot). Linear regressions were established between those parameters before and after freezing. Results are shown in Table 1. The velocity parameters (VAP, VCL, and STR) of the motile sperm were conserved after freezing. Moreover, ejaculates with a high proportion of motile sperm before freezing have, on average, better values for velocity parameters after freezing, while no correlation was found between the percentage of motile sperm before and after freezing. The only parameter of fresh sperm that seems to be correlated with the proportion of motile sperm cells after freezing is MAD (inverse correlation). This could mean that an ejaculate with a high proportion of spermatozoa showing important lateral displacements of the head is more sensitive to cryopreservation. Similarly, a high MAD before freezing was related to a low velocity after thawing. A high MAD could result from a high proportion of capacitated spermatozoa, which is detrimental to their survival and motility. In conclusion, few parameters related to the motility can predict the proportion of motile sperm after freezing. However, by combining several parameters, it seems possible to predict the characteristics of motility of the sperm. Although further investigations are needed, the present evaluation could be of interest to evaluate the freezability of ejaculates, to understand variations between bulls, or to set up new freezing protocols. Table 1 Coefficients of correlation (r2) before and after freezing, calculated from 30 ejaculates from 30 different bulls

Synthesis of functionalized pyrrole and indole derivatives through carbometallation of lithiated double bonds

Bis(2-lithioallyl)amines derived from bis(2-bromoallyl)amines undergo intramolecular carbometallation of a lithiated double bond, giving dilithiated dihydropyrroles. The cyclizations are promoted by N,N,N',N'-tetramethylethylenediamine (TMEDA). Reaction of these intermediates with electrophiles allows the preparation of some new fused and nonfused five-membered functionalized heterocycles. Although 2-lithioallylamines do not suffer intermolecular carbometallation, dimerization products are obtained with their copper or zirconium derivatives. Finally, the application of this new reaction to 2-lithio-N-(2-lithioallyl)anilines leads to 3-lithiomethylindole derivatives, which are transformed to functionalized indole derivatives by reaction with electrophiles.

Identifying bone-mass-related risk factors for fracture to guide bone densitometry measurements: a systematic review of the literature

Available evidence suggests that fracture prediction with bone densitometry may improve when used on people at high risk of osteoporotic fractures. The objectives of this literature review were: (1) to identify risk factors for fracture that are associated with the development of a low bone mass for both men and women; (2) to describe and assess the relationship between these factors and the risk of fracture; and (3) to classify them according to the strength of their association with fracture incidence. Studies were identified from MEDLINE (1982-1997), HealthSTAR (1975-1997) and The Cochrane Library (1997) databases. Pre-stated inclusion criteria (original analytic studies assessing risk factors for osteoporotic fractures in men and women) and methodologic quality were assessed by two independent investigators. Information on the study design and analysis, characteristics of participants, exposure (risk factor) and outcome measures (relative risk and odds ratios for fracture incidence), control for potential confounding factors and risk estimates was extracted using a standardized protocol. Qualitative and meta-analytic techniques were used for data synthesis. As a result, risk factors were classified into three groups according to their strength of association with fracture: high risk (RR > or = 2), moderate risk (1 < RR < 2) and no risk or protective (RR < or = 1). Of approximately 80 risk factors identified from 94 cohort and 72 case-control studies, 15% were classified in the high-risk group, including low body weight, loss of weight, physical inactivity, the consumption of corticosteroids or anticonvulsants, primary hyperparathyroidism, diabetes mellitus type 1, anorexia nervosa, gastrectomy, pernicious anemia, and aging (> 70-80 years). Eighteen percent and 8% of risk factors were classified in the moderate and no risk group respectively, whereas 60% showed either a lack of scientific evidence confirming their association with fracture or contradictory results. An efficient strategy for bone densitometry provision may thus be its selective use in those individuals who present with several strong or moderate risk factors for fracture related to bone mass loss.

Scoring system has better discriminative value than Helicobacter pylori testing in patients with dyspepsia in a setting with high prevalence of infection

OBJECTIVE

To prospectively assess the accuracy of a scoring system to predict organic diseases in dyspeptic patients in an area of South Europe, and to compare it with that of Helicobacter pylori testing in patients with dyspepsia in an environment with high prevalence of H. pylori infection.

METHODS

Symptoms and demographic data were recorded in 501 consecutive dyspeptic patients referred to an outpatient gastroenterology clinic. A simple scoring system was constructed from the predictive factors obtained in a multi-variate logistic regression analysis. Overall predictive accuracy was assessed with the c statistic. The model was validated using bootstrap techniques. The accuracy of clinical judgement and H. pylori testing to predict endoscopic diagnosis was also assessed.

RESULTS

Organic dyspepsia (peptic ulcer, oesophagitis or malignancies) was diagnosed in 45% of the patients. The test for H. pylori was positive in 68%, and 29% of infected patients had an ulcer. The organic dyspepsia predictive model had an accuracy of 0.79, which decreased to 0.77 after validation adjustment. The predictive accuracies for clinical judgement and H. pylori testing were 0.69 and 0.61, respectively. The addition of H. pylori testing to the scoring system resulted in a minor improvement of the predictive accuracy.

CONCLUSION

In an environment with a high rate of H. pylori infection and a low prevalence of peptic ulcer among infected patients, a scoring system has higher predictive accuracy for the diagnosis of organic disease than H. pylori testing. Moreover, in this setting, H. pylori testing adds a minimum value to the predictive capability of the scoring system.

Health technology assessment in Spain

The Spanish Constitution of 1978 established a healthcare system available to everyone and free at the point of service. The General Health Law of 1986 also established the framework for a National Health System (NHS). The Constitution and the law form the regulatory framework for the devolution of healthcare services to the Autonomous Regions. All the 17 Autonomous Regions have complete power regarding public health and planning. However, responsibilities on healthcare financing, organization, provision, and management have devolved to only seven Autonomous Regions. Financial support for health services comes mostly from taxes. Global budgets are a mechanism used by hospitals to control the acquisition of medium and low health technology. Major capital investments for health technology are controlled by the central government in 10 Autonomous Regions (population coverage of 38%) and by the Regional Health Services in the seven remaining Autonomous Regions. In 1995 a regulation for basing the introduction of new procedures and medical equipment on the assessment of safety, efficacy, and efficiency was issued. Health technology assessment (HTA) has a long history in Spain, beginning with the Advisory Board on High Technology in the government of Catalonia in 1984. This board evolved into the Catalan Agency for HTA (CAHTA) in 1994. The Basque Country established a unit for HTA in 1992 (Osteba) and the Andalusian government created an agency in 1996 (AETSA). A national agency for HTA (AETS) was established in 1994. These different programs coordinate their work and together act as an Advisory Committee of the Interregional Council of the NHS.

Health technology assessment and clinical decision making: which is the best evidence?

This paper examines the rationality of the concepts underlying evidence-based medicine and health technology assessment (HTA), which are part of a new current aimed at promoting the use of the results of scientific studies for decision making in health care. It describes the different approaches and purposes of this worldwide movement, in relation to clinical decision making, through a summarized set of specific HTA case studies from Catalonia, Spain. The examples illustrate how the systematic process of HTA can help in several types of uncertainties related to clinical decision making.

The Role of Scientific Knowledge for Decision Making in Health Care: Myth or Reality?

Decision makers' information needs in present day health care systems are growing at the same pace as the need to manage economic and health care resources more rigor ously. It is in the new socioeconomic and demographic scenarios and within a better informed society—demanding explanations about how and in what their tax money is spent—where we find the source of this need, and of the appreciation ofscientific know ledge as a way to inform the different types of decisions being made in health care systems

This paper examines briefly the evolution of health-related research and its influ ence in clinical practice and health care management. It also explores the rationality of the potential conflict between the main decision makers in health care: doctors and managers. Finally, it states the experience of a health technology assessment agency as an approach for the management of knowledge.

Open heart surgery in public and private practice

OBJECTIVES

To compare open heart surgery services provided by public and private hospitals in Catalonia (Spain) according to case mix, procedures undergone and surgical mortality.

METHODS

Data on all adult patients undergoing open heart surgery procedures were collected prospectively in a sample of public and privately owned centres for a 6.5-month period in 1994. Sociodemographic, clinical and procedural variables were collected. A predictive model stratifying patients according to their surgical mortality risk was used to adjust for differences in case mix between providers.

RESULTS

Included were 1287 open heart surgery procedures. Public and private patients differed significantly in terms of gender, clinical history (e.g. hypertension, pulmonary disease, recent infarction) and procedural variables (e.g. reoperation, type of intervention). There were also statistically significant differences related to educational level, with better educated patients more likely to be treated in private centres. Crude surgical mortality rates differed between providers, although public centres operated on higher-risk patients. After adjusting for differences in case mix, the association between the type of provider and surgical mortality was not statistically significant (odds ratio 1.68; 95% CI from 0.94 to 3.0).

CONCLUSIONS

Although crude mortality rates differ between public and private providers, there is a significant trend towards higher surgical risk in public centres. After adjusting for surgical risk, differences between types of provider decreased and were no longer statistically significant. The importance of other social and health-related factors, such as educational level, may explain differences between providers in their patients' surgical risk and in their performance in open heart surgery.

Subjective versus statistical model assessment of mortality risk in open heart surgical procedures

BACKGROUND

The aim of this study was to compare the predictive accuracy for open heart surgical mortality between a statistical model based on collection of clinical data and surgeons' subjective risk assessment.

METHODS

Predictive discrimination of both risk assessments (surgeons' and model) was compared through the area under the receiver operating characteristic curve. Logistic regression analysis was used to assess the relation between surgeons' and model predictions to actual outcomes. Calibration of the subjective estimates was evaluated with a chi2 test.

RESULTS

Overall, the area under the receiver operating characteristic curve was 0.76 for the statistical model and 0.70 for the subjective assessment. Logistic regression analysis showed that the statistical model remained significant after accounting for the subjective assessment. Calibration of subjective mortality predictions was poor.

CONCLUSIONS

Surgeons' risk assessment tends to cluster in the middle ranges of risk. Subjective assessment seems accurate in identifying the two extremes of risk but is inaccurate for intermediate risk levels. A multivariate statistical model improves the accuracy of subjective predictions.

Cardiac surgical mortality: comparison among different additive risk-scoring models in a multicenter sample

OBJECTIVE

To compare the performance of several risk-scoring models to predict surgical mortality following open heart surgery.

DESIGN

A prospective observational study.

SETTING

Seven tertiary cardiac centers (3 private and 4 public and teaching hospitals) in Catalonia (Spain).

PATIENTS

A consecutive sample of 1287 patients submitted to open heart surgery during a 6 1/2-month period (February 14, 1994, to August 31, 1994).

INTERVENTION

None.

MAIN OUTCOME MEASURE

Model discrimination capability was assessed with the c-statistic. A chi(2) test to compare observed and predicted mortality rates was used as a measure of model calibration. Performance of centers was evaluated through the standardized mortality ratio and using the center as an indicator variable in a logistic regression model. The agreement among models for individual predictions was tested using weighted K statistics.

RESULTS

Models developed in other health care contexts showed, as expected, lower c-statistics and an inappropriate calibration. There were no statistically significant differences among hospitals after adjusting for baseline patients' risk factors with the use of any of the different models. Models also agree in the standardized rank of centers. Weighted K statistics indicated poor agreement among models for individual patient risk prediction.

CONCLUSIONS

Models can be a useful tool to compare providers' performance and to give a more in-depth look at the process of care when appropriately customized to the context. Severity-adjusted models can also play a role in supporting the informed and subjective surgeon's assessment, but it is inappropriate to use them for individual predictions.

The effectiveness of bone density measurement and associated treatments for prevention of fractures. An international collaborative review

This review assesses the evidence regarding the effectiveness of bone density measurement (BDM) screening and related interventions--hormone replacement therapy (HRT) and intranasal salmon calcitonin (SCT[N])--in menopausal women to prevent fractures in later life. Data sources included systematic reviews of evidence and relevant primary studies identified through literature searches on MEDLINE and EMBASE. Study selection included trials of BDM screening programs, prospective studies examining the predictive value of BDM, randomized controlled trials, cohort studies, and case-control studies of HRT and SCT (N). The evidence was evaluated using a classification system incorporating study design and quality. Outcomes were measured in terms of relative risk of fracture for a 1 SD decrease in bone mineral density below the age-adjusted mean, relative risks or odds ratios for fractures associated with treatments, and proportion of hip fractures potentially prevented by BDM screening linked to treatments. Fair evidence from prospective cohort studies suggests that BDM can predict the risk of fractures, but not with high accuracy. Fair evidence from low-quality randomized controlled trials and observational studies suggests that HRT and SCT(N) are efficacious in preventing fractures. Good evidence supports the efficacy of these treatments in preserving bone mass, but there is fair evidence that the effect wears off after cessation of therapy. There is little evidence on the impact of screening menopausal women with BDM in association with HRT or SCT(N) treatment. Estimates based on combining existing evidence regarding the predictive value of BDM and efficacy of HRT suggests that 1-7% of hip fractures might be prevented.

Anticipating the consequences for the primary therapy of breast cancer after introducing screening. A more global picture for health care policy making

A breast cancer screening program mainly aims at reducing mortality. However, it also has an effect, often not assessed, on the utilization of health care resources that is relevant to health care policy making. Using a simulation model, this paper forecasts the impact of introducing a breast cancer screening program on the utilization of resources for the primary therapy of breast cancer. The most important consequences from a health care point of view will be an increased use of breast-conserving therapy and an increased need for postoperative radiotherapy; there will also be a higher number of women diagnosed with noninvasive breast cancer. The results of this study could provide support for health care decision making by showing the consequences of policy decisions on the introduction of screening programs for health care utilization.

International collaboration in health technology assessment: a study of technologies used in management of osteoporosis

A collaborative study was undertaken by members of the International Network of Agencies for Health Technology Assessment (INAHTA). The evidence of the effectiveness of bone density measurement and selected treatments in preventing fractures in later life was reviewed. There was fair evidence that bone density measurement can predict risk of fractures and that hormone replacement therapy and intranasal salmon calcitonin preserve bone mass and decrease the risk of fractures. However, it was estimated that only 1-7% of hip fractures would be prevented if these technologies were used in a screening program for menopausal women. Results of the assessment were endorsed by 13 INAHTA members, disseminated widely and provided input to policy and further work in this area. The project demonstrated the feasibility of international collaborative health technology assessment.

EUR-ASSESS Project Subgroup Report on Dissemination and Impact

The objective of health technology assessment (HTA) is to support decision making in health care. HTA does not claim to provide a definite solution to a health care problem, but to assist decision makers with evidence-based information about the clinical, ethical, social, and economic implications of the development, diffusion, and use of health care technology.

Priority setting for health technology assessment. Theoretical considerations and practical approaches. Priority setting Subgroup of the EUR-ASSESS Project

This report is about setting priorities for health technology assessment (HTA). HTA examines systematically the consequences of the application of health technologies (broadly defined to include any health care intervention) to support decision making in policy and practice. Only a fraction of existing health technologies have been formally evaluated, and many more appear each year. Resources for HTA are, however, limited so that priorities have to be set, whether explicitly or implicitly. The aim of setting priorities for HTA should be to identify those assessments that offer the greatest benefits in relation to their cost, and thus to maximize the benefit derived from investments in HTA.

Assessing open heart surgery mortality in Catalonia (Spain) through a predictive risk model

OBJECTIVE

To develop a risk stratification model to assess open heart surgery mortality in Catalonia (Spain) in order to use risk-adjusted hospital mortality rates as an approach to analyze quality of care.

METHODS

Data were prospectively collected through a specific data-sheet during 6 1/2 months in consecutive adult patients subjected to open heart surgery. The dependent variable was surgical mortality, and independent variables included were presurgical (sociodemographic data, clinical antecedents, morphological and functional studies) and surgical. The model was built on a subsample (70% of study population) through univariate and logistic regression analysis and validated in the rest of the sample.

RESULTS

The total sample was of 1309 procedures in seven hospitals; 47% of them were valve procedures. The overall crude mortality rate was 10.9% and varied among centers (range, 2.8-14.8%). Risk factors included in the model received a weight based on the logistic regression coefficient and a score was generated for each patient. The factors with the highest weight were patient older than 80 and second reoperation. Score was stratified in five categories of increasing risk. There was a good agreement between observed and predicted mortality rates in the validation group. Overall patient distribution was as follows: 52% low risk level, 16% fair, 13% high, 12% very high, and 6% extremely high risk level. Mortality rate increased from 4.2% in the low risk to 54.4% in the highest risk group. Case mix adjustment was performed through the risk score level. There were statistically significant differences in the risk profiles of patients admitted among centers. After adjustment by risk profiles, there were no differences in mortality by hospital.

CONCLUSION

A risk stratification model through a multicentric, prospective and exhaustive collection of data in all types of open heart procedures was developed. In spite of wide differences on crude rates and in the risk profiles of patients admitted, we did not find statistically significant differences in adjusted mortality rates among centers. Timely and accurate information about surgical outcomes can lead to improvements in clinical practice and quality of care.

The importance of process variables analysis in the assessment of long-term oxygen therapy by concentrator

The aim of the present study was to evaluate process variables and intermediate outcomes involved in long-term oxygen therapy (LTOT) by concentrator with the purpose of identifying which of those factors would be the most influential in the final health outcome of the therapy. A cross-sectional survey was carried out on a random sample of 111 patients receiving LTOT by concentrator in Catalonia (Spain). Patients were interviewed and assessed at home by a trained physician, and the variables collected were arterial oxygen saturation, performance of the concentrators, and patient compliance. Sixty-two patients participated in the study. Overall, LTOT was appropriately prescribed in 36 patients, of whom only 29 were able to correct their level of hypoxaemia. Patient compliance with treatment was considered adequate in 19 of those 29 patients. Thus, only 19 of 62 patients (31%) fulfilled those criteria needed to achieve the expected clinical benefits. Strategies for improving the effectiveness of medical interventions or technologies ought to consider those factors of the therapeutic process which might influence the expected health outcomes in a specific health-care context.

Comparison of partially attended night time respiratory recordings and full polysomnography in patients with suspected sleep apnoea/hypopnoea syndrome

BACKGROUND

Laboratory full polysomnography (PSG) is considered to be the gold standard for the diagnosis of the sleep apnoea/hypopnoea syndrome (SAHS), but it is expensive and time consuming. A study was undertaken to evaluate the diagnostic usefulness of a partially attended night time respiratory recording (NTRR) and a clinical questionnaire in patients with suspected SAHS in comparison with full PSG.

METHODS

Seventy six patients (54 men) of mean (SD) age 51 (11.5) years with a body mass index of 31 (5.7) kg/m2 were studied at random on two different nights with full PSG at the sleep laboratory and with NTRR on a respiratory ward. NTRR records oximetry, airflow, chest and abdominal motion. All signals were continuously displayed on a computer screen throughout the night and respiratory events were scored automatically the following morning. All patients completed a clinical questionnaire.

RESULTS

Mean values of the apnoea/hypopnoea index (AHI) using NTRR were lower than those obtained with full PSG (22.7 (2.4) versus 32.2 (3) events/hour) which was mainly due to underrecognition of hypopnoeas. Sensitivity and specificity of NTRR for the diagnosis of SAHS were 82% and 90%, respectively, taking as reference AHI > 10 on full PSG (AHI-PSG > 10). The mean (+/-2SD) difference in AHI between the two methods was 9.6 (range -5.4-24.6) (95% confidence interval 6.2 to 13). Symptoms of witnessed apnoeas, impotence, the overall clinical impression of a trained physician, and a neck size over 40 cm were significantly more prevalent in patients with AHI-PSG of > 10, but impotence was the only clinical feature significantly more prevalent in patients with false negative compared with true negative NTRR results that helped to distinguish patients with NTRR < 10 but AHI-PSG > 10.

CONCLUSIONS

NTRR is a helpful and easy complementary diagnostic tool in clinical practice because it detects patients with moderate to severe SAHS reasonably well and therefore can be useful for confirming a diagnosis of SAHS and also for treatment decisions. It is suggested that patients with suspicion of SAHS should be initially studied by NTRR. When NTRR is negative, a full PSG should be performed if witnessed apnoeas, impotence, systemic hypertension, ischaemic heart disease, and a trained physician's clinical impression of SAHS are present.

Quality of life, major medical complications and hospital service utilization in patients with primary biliary cirrhosis after liver transplantation

AIMS/METHODS

Major medical complications, hospital service utilization and quality of life were investigated in 26 out of 29 consecutive primary biliary cirrhosis transplanted patients who survived at least 2 years after the procedure (90% survival rate).

RESULTS

Before liver transplant, the most relevant clinical data were jaundice (96%), pruritus (92%), ascites (50%), gastrointestinal bleeding (19%), hepatic encephalopathy (12%) and bone pain (12%). During the first postoperative year, the most significant complications were bone pain (58%) and fractures (31%), arterial hypertension (50%), and mild/moderate renal failure (46%). The frequency of these complications remained similar during the second year, but there was a significant reduction in the incidence of bone fractures. Bone pain was the only postoperative complication which correlated with an increased number of unscheduled outpatient and emergency visits. Quality of life was measured cross-sectionally either at or after the second postoperative year. The Karnofsky index was 90 in 69% of the patients and 76% were able to perform usual daily activities. Self-assessed health perception was good or very good in almost all the patients. However, the Nottingham Health Profile showed that approximately 70% of the patients gave a positive response to some questions in areas of pain, sleep, emotional reactions and physical activities.

CONCLUSIONS

The results of the present study confirm that patients with primary biliary cirrhosis have a high survival rate after liver transplantation and that bone pain and fractures are important postoperative complications. Good self-perceived health and return to daily activities evidenced in most PBC patients should be balanced with problems identified by more specific tools, which could have an impact on the health service utilization and quality of life.

[Immunologic characteristics of undernutrition. I. The undernourished patient in nutritional recovery]

Malnutrition in children is a well known critical factor that determines immunocompetence changes with altered immune response and higher risk to many diseases, especially in developing countries. Moreover, it is related to increased morbi-mortality rates mainly due to infections. For those reasons, 12 undernourished children, age 5 to 24 months were studied along 8 weeks at the Nutritional Recovery Center of Chiquinquira Hospital in Maracaibo, Venezuela. There were 5 cases of kwashiorkor, 5 marasmatics, 1 mixed marasmus/kwashiorkor and 1 case with moderate malnutrition. After a control blood sample was taken and cutaneous tests were done, a nutritional recovery program was began. At regular time intervals and at the end of the study, tests were done again by measuring seric immunoglobulins (IgG, IgA, IgM), secretory IgA (IgAs), C3 and C4 complement, lymphocytic sub-populations, and auto antibodies; cutaneous hipersensitivity tests were also done. As a control group, 10 apparently healthy children of matching age and sex were also studied with the same parameters. Results show that basal seric Igs did not differ significantly from the control group and did not change along the recovery program period, but there was a significant decrease in IgAs at all times of the study. C4 did not change and C3 was lower than control (p < 0.05) but returned to normal value at the end of the recovery period. CD3 and CD4 lymphocytes showed the same pattern. Only two patients showed positive skin tests and auto antibodies were not detected. It is concluded that there is indeed an altered immune competence with low levels of C3, IgAs, and CD3-CD4 lymphocytes that is reversible after nutritional recovery.

[Physicochemical evaluation of dried salted fish in Venezuela]

Several physical and chemical characteristics of dried salted fish obtained from Venezuelan's market were evaluated. Determinations of moisture, ash, fat, protein, pH, sodium chloride. Total Volatile Nitrogen and water activity, were performed on such products. Even though on limiting parameters, the values of water activity, moisture and NaCl determination, indicated that the fish quality was acceptable. Total Volatile Nitrogen and pH values were related more to the particular fish species. Four different fish species were salted and dried following the "optimal method", and an excellent product was obtained, without using expensive or complex methods.

[Appropriate use and effectiveness of chronic domiciliary oxygen therapy in Catalonia]

BACKGROUND

The aim of this study was to study the pattern of the use of chronic domiciliary oxigenotherapy (CDO) in Catalonia, Spain.

METHODS

A transversal study including 110 patients randomly selected from a list of all the subjects with CDO (n = 3,585) was made. A domiciliary survey on the characteristics of the indication for CDO and its fulfillment was carried out. Two pulsioximetries were also performed one breathing room air and another with oxigen.

RESULTS

Of the 70 eligible patients the following factors were simultaneously observed in only 14 (20% of the total): adequate indication for CDO, use of oxigen at a flow which corrected the hypoxemia, and prescription fulfillment. The most important cause of inadequate usage of CDO was inappropriate indication since only 19 patients (27%) presented SaO2 less than or equal to 88%. Hypoxemia was not corrected in four of these 19 patients. Thirty-seven percent of the total admitted bad fulfillment, bot only one of the 15 patients with SaO2 less than or equal to 88% and in whom hypoxemia was corrected, recognized bad fulfillment. Sixty-nine percent of the patients had a document explaining the way and length of time they should receive the oxigen.

CONCLUSIONS

The inappropriate indication of CDO is the main factor influencing the low effectiveness of chronic domiciliary oxigenotherapy in Catalonia.

Complex decisions about an uncomplicated therapy: reimbursement for long-term oxygen therapy in Catalonia (Spain)

Therapies used in the management of chronic diseases cause specific problems regarding reimbursement policy. Oxygen therapy is an example of such treatments that receive little attention from health care policy makers, due to their low cost to the health care budget and to their little importance from a social point of view. In this paper, we analyze the problems posed by this therapy in the Catalan health care system, as an example of the several aspects implied in the reimbursement of such kind of therapies. A technology assessment of this therapy was carried out showing that a change in the reimbursement of long-term home oxygen therapy (LTOT) was needed. Slow diffusion of new oxygen delivery modalities and over-prescription of LTOT were among the problems observed. The new system proposed is presented, and some preliminary results and consequences of the role of technology assessment in health care policy-making are discussed.

Randomised trial of corticosteroids in the treatment of tuberculous pleurisy

BACKGROUND

Tuberculous pleurisy can result in pleural fibrosis, calcification and thickening. To prevent these complications, corticosteroids are frequently used in addition to antituberculous drugs; however, new therapeutic regimens can control the disease and minimise the sequelae, and there is no convincing evidence of the benefit of the use of corticosteroids as adjuvant therapy.

METHODS

Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Additionally, they were randomly assigned to a double blind treatment with either prednisone (1 mg/kg/day for 15 days and then tapering off) or placebo during the first month of treatment. Different clinical, radiological, and functional parameters were evaluated to assess the effect of corticosteroids.

RESULTS

Fifty seven patients received prednisone and 60 placebo. At the end of the treatment the clinical outcome, the rate of reabsorption of the pleural fluid, the pleural sequelae, as well as lung capacity were similar in both groups.

CONCLUSIONS

Corticosteroids do not influence the clinical outcome or the development of long term pleural sequelae in tuberculous pleurisy.

[Approach to the use of screening mammography in 2 health regions]

OBJECTIVE

To find the present use of mammography screening in relation to the reference criteria on what age to begin breast cancer screening, as defined in the Health Plan for Catalonia, and to evaluate the activity of the mammography technicians.

DESIGN

Crossover survey.

SETTING

The Costa de Ponent and Centre de Cataluña Health Regions.

PATIENTS

There were 1,587 mammography requests from patients seen in these health sectors.

MEASUREMENTS AND MAIN RESULTS

The variables collected were age, date of investigation, place of residence, reason for request. 45.4% of screening mammographies requested in the health sectors under study corresponded to the age-group recommended in the reference criteria. Similar results were observed in the centres where mammographies were performed. Average daily activity per mammogram technician is 11.1 investigations (average: 11.1 mammographies; SD 4.5).

CONCLUSIONS

About half the mammographies performed as part of screening for breast cancer are performed outside the recommended age-group and for ages where effectiveness has not been demonstrated. Therefore, publicising the recommended screening criteria must be a priority when initiating preventive activities. It is also important to use the available resources efficiently in line with the criteria laid down for breast cancer screening.

[Compliance with nasal continuous positive airway pressure (CPAP) treatment in sleep apnea-hypopnea syndrome]

Ever since Sullivan introduced nighttime nasal continuous pressure on the upper airway (CPAP) in 1981 it has been the standard treatment for sleep-hypopnea syndrome (SAHS). However, CPAP is carried out at great expense and is not tolerated by all patients. Moreover, its efficacy is dependent on the degree of compliance. In this study we set out to analyze the degree of compliance with CPAP over the first 3 months of treatment in a group of 142 consecutive patients with moderate to severe SAHS (apnea-hypopnea index: 48.9 +/- 20). Diagnosis and measurement of the level of CPAP needed (9.6 +/- 2.5 cm H2O) were based on polysomnography. Eighteen (13%) patients did not return for follow-up evaluation. In the remaining 124 patients (age 54 +/- 11 years) compliance with treatment was evaluated by way of a sleep diary in which the patient recorded the hours CPAP was used at night; this record was compared with readings from the CPAP generator's counter. All subjects were asked about their degree of sleepiness before treatment by way of a standard questionnaire. Although most patients reported regular use of CPAP in diaries, only about 60% actually used it for longer than a mean 4.5 hours daily. The most compliant patients could not be differentiated from the least compliant with respect to degree of initial sleepiness, apnea-hypopnea-per-hour index or level of CPAP required.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculous pleural effusion: experience with six months of treatment with isoniazid and rifampicin

BACKGROUND

Tuberculous pleurisy is associated with small numbers of bacteria. Due to the low rate of primary resistance to antituberculous drugs a two-drug regimen was used to treat the condition.

METHODS

Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Clinical, radiological, and haematological assessments were performed during treatment and patients were followed up for a median period of 41 (range 6-96) months.

RESULTS

One hundred and thirty patients were studied with a mean age of 27 (range 11-53) years. Seven were withdrawn due to parenchymal disease and eight were lost to follow up during the treatment period. Side effects during treatment were frequent (20.7%), but only three patients required a change in medication. No treatment failures were observed. One hundred and fifteen patients completed therapy and were followed up for 41 (range 6-96) months with no evidence of a relapse.

CONCLUSIONS

Tuberculous pleurisy responds well to a two-drug regimen of antituberculous therapy given for six months.

Technology assessment in Catalonia: integrating economic appraisal

A brief description of the evolution and role of the Catalan Office for Health Technology Assessment (COHTA) into the framework of the Catalan Health Care Service are presented. Methodological approaches used by COHTA range from synthesis of scientific evidence to the collection of primary data. Regarding the integration of economic appraisal into technology assessment, the main approaches are the following: integration into clinical trials funded by the COHTA and in the reimbursement policies of the Catalan Health Service. COHTA participates in the process of purchasing medical technologies, especially expensive ones, and in the establishment of reimbursement policies of medical technologies. The particular characteristics of COHTA as a regional agency for Technology Assessment and its position into the framework of the Department of Health are discussed. Among the advantages of this position are the knowledge of the relevant questions for policy makers and the potential influence in the process. Among the disadvantages are the possibility of losing autonomy. Regional agencies that are closely related to the regional health services could provide a better understanding of the real problems in clinical practice and in the utilization of health technologies.

[Cardiological evaluation of the asthmatic adult in the allergologist's office]

The basic and clinic measurements in the initial cardiovascular work-up of the adult asthmatic are reviewed. This is complemented with the physiopathology of the two problems the frequently arise when an asthmatic is evaluated: 1) if asthma could cause a heart disease and 2) if a heart disease may be hidden in a presumed asthma.

Pneumonia due to Legionella pneumophila and pneumococcal pneumonia: similarities and differences on presentation

We compared clinical, radiological and laboratory data from 32 cases of community-acquired pneumonia due to Legionella pneumophila, with 37 cases of pneumococcal pneumonia (PP). This study revealed few clinical differences between the two types of pneumonia: in our experience Legionnaire's disease presents like a "typical" bacterial pneumonia. Given the difficulty of making a diagnosis on clinical data alone, we propose early aetiological diagnostic measures and recommend that the choice of initial treatment be based not only on the features at the time of presentation, but also on a consideration of the epidemiology of different types of pneumonia in a given area.

Pneumonia due to Legionella pneumophila and pneumococcal pneumonia: similarities and differences on presentation

We compared clinical, radiological and laboratory data from 32 cases of community-acquired pneumonia due to Legionella pneumophila, with 37 cases of pneumococcal pneumonia (PP). This study revealed few clinical differences between the two types of pneumonia: in our experience Legionnaire's disease presents like a "typical" bacterial pneumonia. Given the difficulty of making a diagnosis on clinical data alone, we propose early aetiological diagnostic measures and recommend that the choice of initial treatment be based not only on the features at the time of presentation, but also on a consideration of the epidemiology of different types of pneumonia in a given area.