Cost-effectiveness analysis of five pharmacological strategies for the first-line treatment of patients with neuropathic pain in Colombia

ABSTRACT: Materials and methods: A decision tree was constructed comparing amitriptyline, duloxetine, gabapentin, oxcarbazepine, pregabalin, tramadol and no treatment. The transition probabilities were obtained from a study identified in a systematic review of clinical literature. Costs were measured by expert consensus using the standard case methodology, and resource valuation was carried out using national-level pricing manuals. Deterministic sensitivity, of scenarios, and probabilistic analyses were carried out. Results: pregabalin proved to be the strategy with the best cost-effectiveness relationship, followed by gabapentin and amitriptyline. This result stands in almost all the sensitivity analyses performed, and only changes when the probability of pain reduction of more than 30 % was less than 14 % for pregabalin. Conclusions: pregabalin is a cost-effective alternative, and could be considered as the first-line treatment of patients with neuropathic pain in Colombia. Gabapentin and amitriptyline obtained a similar costeffectiveness relationship, and could be considered as alternatives according to the particular characteristics of each patient and the physician judgement and experience.RESUMEN: Determinar la relación de costo-efectividad de cinco estrategias farmacológicas para el tratamiento de primera línea de pacientes con dolor neuropático en Colombia. Materiales y métodos: se construyó un árbol de decisiones que compara amitriptilina, duloxetina, gabapentina, oxcarbazepina, pregabalina, tramadol y la opción de no tratamiento. Las probabilidades de transición se extrajeron de un estudio identificado en una revisión sistemática de la literatura clínica. Los costos se identificaron con la metodología caso tipo, mediante consenso de expertos, y la valoración de los recursos se llevó a cabo con manuales tarifarios de alcance nacional. Se hicieron análisis de sensibilidad determinísticos, de escenarios y probabilísticos. Resultados: pregabalina resultó ser la estrategia con la mejor relación de costo-efectividad, seguida de gabapentina y amitriptilina. Este resultado se mantiene en la mayoría de los análisis de sensibilidad, y solo se modifica cuando la probabilidad de disminuir el dolor en más del 30 % es inferior al 14 % para pregabalina. Conclusiones: la pregabalina es una alternativa costo-efectiva, por lo que puede ser considerada como tratamiento de primera línea de pacientes con dolor neuropático en Colombia. Gabapentina y amitriptilina obtuvieron una relación similar de costos y beneficios, y también podrían considerarse como alternativas de acuerdo con las características particulares de cada paciente y con el criterio y la experiencia del médico tratante

Clinical Practice Guide for diagnosis and preoperative, intraoperative and postoperative treatment of the person with amputation, prosthetic prescription and integral rehabilitation

ABSTRACT: This article summarizes the recommendations on functional assessment scales, physical and cardiopulmonary rehabilitation programs, treatments for postamputation pain, occupational assessment, ergonomic adaptations and job reinstatement.RESUMEN: En este artículo se resumen las recomendaciones acerca de las escalas de evaluación funcional, los programas de rehabilitación física y cardiopulmonar, los tratamientos para el dolor postamputación, la evaluación ocupacional, las adaptaciones ergonómicas y el reintegro laboral

Validez diagnóstica del FilmArray Meningitis/Encephalitis (ME) panel para diagnóstico de infecciones del Sistema Nervioso Central. Revisión sistemática y metanálisis

RESUMEN: Introducción: los métodos tradicionales para realizar diagnóstico de neuroinfección aguda son sub-óptimos. El FilmArray Meningitis/Encephalitis panel (BioFire Diagnostics) (FA/ME) aprobado por la FDA en el 2015 trae beneficios en la práctica clínica pero aún no está clara su validez diagnóstica y aplicabilidad. Métodos: Realizamos una revisión sistemática de la literatura y metanálisis de pruebas diagnósticas. Hicimos búsqueda en Embase, Medline (vía Ovid), y Web of Science hasta octubre de 2019, y en literatura gris. Evaluamos riesgo de sesgo con QUADAS 2. Incluimos estudios de prueba diagnóstica o de corte transversal, que realizaran de manera simultánea la prueba de referencia (cultivo de LCR o hemocultivo para bacterias, y PCR específica o LDT –Laboratory Developed Test- para virus) y la prueba FA/ME en pacientes con sospecha de neuroinfección. Realizamos metanálisis de efectos aleatorios y calculamos sensibilidad, especificidad, LR+, LR+ y Odds Ratio de diagnóstico, para estudios que usaron como prueba diagnóstica el cultivo bacteriano (Prueba de referencia1), y para aquellos con diagnóstico de infección según criterios clínicos y/o de laboratorio (prueba de referencia 2). Resultados: Incluimos 14 estudios con 5197 pacientes. Todos los estudios presentaron riesgo de sesgos. Para el análisis de todas las bacterias con prueba de referencia 1 se incluyeron 12 artículos con 4228 pacientes, se obtuvo sensibilidad combinada de 86% (IC95% 78 a 92), especificidad de 98%(IC 95% 95 a 99), LR+ 43.2 y LR-0.14. Para el análisis de todas las bacterias con prueba de referencia2una sensibilidad combinada del FA/ME de 97% (IC 95% 91 a 99), especificidad de 99% (IC95% 98 a 99), LR+ 286.1 y LR- 0.024. Para un total de 179 bacterias detectadas por FA/ME y/o prueba de referencia, 90 (50.2%) fueron consideradas verdaderos positivos (VP)y 89 (49.7%) falsos positivos (FP) respecto a la prueba de referencia 1; y al aplicar prueba de referencia 2(método de laboratorio o clínico adicional), 160 (89.3%) se consideraron VP y 19 (10.6%) FP. Discusión: FA/ME tiene un buen rendimiento diagnóstico para bacterias y enterovirus, aunque los estudios tienen riesgos de sesgos considerables. No fue posible evaluar la validez diagnóstica para otros virus por falta de prueba de referencia, de una metodología adecuada y/o por información incompleta en los estudiosABSTRACT: Introduction: Traditional methods for diagnosing acute neuroinfection are suboptimal. The 2015 FDA-approved Meningitis / Encephalitis FilmArray (BioFire Diagnostics) (FA / ME) panel brings benefits in clinical practice but its diagnostic validity and applicability remain unclear. Methods: We performed a systematic review of the literature and meta-analysis of diagnostic tests. The search strategy was performed in Embase, Medline (via Ovid), and Web of Science until October 2019, and gray literature was searched. We assessed the risk of bias with the QUADAS 2 tool. Studies with a diagnostic or cross-sectional test design were included, which simultaneously measured the gold standard (CSF culture or blood culture for bacteria, and specific PCR or LDT - Test developed in the laboratory - for viruses) and the FA / ME test in patients with suspected neuroinfection. We performed meta-analyzes for calculations of combined measures of validity (Sensitivity, specificity, LR +, LR + and diagnostic Odds Ratio), with the information from studies that used culture of CSF or blood in the diagnostic test (Gold Standard 1), and for those who require, they used the final infection allocation based on clinical and / or laboratory criteria (gold standard 2). Results: In total we included 14 studies with 5197 patients in the meta-analysis. For the analysis of all the bacteria with gold standard1, 12 articles with 4228 patients are included, and a combined sensitivity of 86% (95% CI 78 to 92), specificity of 98% (95% CI 95 to 99), LR + 43.2 and LR- 0.14. For the analysis of all the bacteria with gold standard 2, a combined sensitivity of the FA / ME of 97% (95% CI 91 to 99), specificity of 99% (95% CI 98 to 99), LR + 286.1 and LR- 0.024. For a total of 179 bacteria detected by FA / ME and / or gold standard, 90 (50.2%) were considered TP (true positive) and 89 (49.7%) FP (false positive) with respect to gold standard 1; and with gold standard2 (additional clinical or laboratory method), 160 (89.3%) were considered TP and 19 (10.6%) FP. Discussion: FA / ME seems to have good diagnostic performance for bacteria. It is not possible to assess the diagnostic validity of the virus due to a lack of gold standard, an adequate methodology in the studies and / or incomplete informatio

Colombian surgical outcomes study insights on perioperative mortality rate, a main indicator of the lancet commission on global surgery – a prospective cohort studyResearch in context

Summary: Background: Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia. Methods: A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions. Findings: 3807 patients were included with a median age of 48 (IQR 32–64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien–Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68–12.76) and any complication (31.6%, 30.09–33.07). POMR stood at 1.9% (1.48–2.37), with elective and emergency surgery mortalities at 0.7% (0.40–1.23) and 3% (2.3–3.89) respectively. Interpretation: The POMR was higher than the ratio reported in previous national studies, even when patients had a low–risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care. Funding: This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017