Costo-beneficio de cribado de adenocarcinoma gástrico por pepsinógeno sérico en la población mexicana

Resumen: Introducción y objetivo: Se sabe que Helicobacter pylori (H. pylori) es capaz de provocar inflamación crónica de la mucosa gástrica, que progresa lentamente a través de las etapas premalignas hasta llegar al adenocarcinoma gástrico (ACG) localizado; su pronóstico está estrechamente relacionado con la etapa en la que realiza el diagnóstico. El propósito de este estudio es determinar el costo-beneficio mediante la comparación de la esofagogastroduodenoscopia, la detección de pepsinógeno en suero o no realizar ningún cribado. Material y métodos: Utilizando cadenas de Markov y simulación de Monte Carlo se simularon los costos y los efectos de varias modalidades de detección para analizar el costo-beneficio obtenido de cada una. Para nuestra población, utilizamos los datos publicados de pacientes con cáncer gástrico, aplicables a la población mexicana. Resultados: Los resultados se informaron en proporciones incrementales de costo-efectividad. La mejor estrategia fue buscar pepsinógeno en suero, seguido de una prueba de estrategia de examen endoscópico con vigilancia continua cada 3 años. Conclusiones: La detección de pepsinógeno en suero, así como la detección endoscópica dirigida (y la vigilancia continua, si es necesario) para el cribado de ACG podría ser una intervención rentable en México a pesar de una prevalencia general de la enfermedad de baja a moderada. Abstract: Introduction and aim: Helicobacter pylori (H. pylori) is known to be capable of causing chronic inflammation of the gastric mucosa that slowly progresses through the premalignant stages, reaching localized gastric adenocarcinoma (GAC). Its outcome is closely related to the stage at which diagnosis is made. The aim of the present study was to determine cost-benefit by comparing esophagogastroduodenoscopy, serum pepsinogen detection, and no screening at all. Material and methods: Utilizing Markov chains and Monte Carlo simulation, the costs and effects of various detection modalities were simulated to analyze the cost-benefit of each strategy. For our population, we used the published data of patients with gastric cancer, applicable to the Mexican population. Results: The results were reported as incremental cost-effectiveness ratios. The best strategy was serum pepsinogen determination, followed by the strategy of endoscopic examination with continued monitoring every 3 years. Conclusions: The performance of serum pepsinogen serology and directed endoscopic examination (and continued monitoring, if necessary) for GAC screening could be a cost-effective intervention in Mexico, despite the low-to-moderate general prevalence of the disease

Recomendaciones generales apra mejorar la calidad de la atención obstétrica

INTRODUCTION. Maternal care means roughly a half of medical interventions, hospital discharges and surgery realized in Mexico. Obstetrics reached the second place (14.5%) in malpractice complaints in National Commission of Medical Arbitration (CONAMED). OBJECTIVE: To analize the CONAMED�s experience about obstetric care claims, and profit recommendations for medical practice. METHOD: The authors revised 1431 complaints ob/gin-related, placed in CONAMED between june 1996 to june 2001, and selected a sampling of 121 cases of ruling reports. We describe sociodemographic, institutional, clinical, communication and lawattach indicators. RESULTS. Complaints were originated in third quarter of pregnancy (82.8%), in social-security services (72.1%), in second level hospitals (62.3%). Fifty seven percent were high risk pregnancies, with previous cesarean section as frequent medical historial (21.5%). The complications were predictable in almost half of cases. First medical error was a deficient labor surveillance (22.3%). Malpractice was identified in 54.5%, ethical mistakes in 30%, institutional insufficiencies in 40.5%, inaccurate medical records in 45% and inadequate communication in 76%. CONCLUSIONS. An accurate obstetric care is composed by proffesional sense of duty and ethics, conscientious patient care, identify high risk pregnancies, recognize personal and institutional skill restrictions, to know health laws, and effective physician - patient communication. We declare 9 recommendations for medical and paramedical who care obstetric patients.ANTECEDENTES. La atención materna representa aproximadamente la mitad de las intervenciones médicas, egresos hospitalarios y las cirugías que se realizan en México. Las demandas por mala práctica relacionadas con atención obstétrica alcanzaron el segundo lugar (14.5%) de los asuntos atendidos por CONAMED. OBJETIVO. Analizar la experiencia de CONAMED sobre conflictos por atención obstétrica y expresar recomendaciones para la atención de estas pacientes. METODOLOGÍA. Se revisaron 1431 inconformidades relacionadas con atención ginecoobstétrica, radicadas en CONAMED entre junio de 1996 hasta junio de 2001. Se seleccionó una muestra dirigida de 121 casos concluidos por dictamen pericial. Se describen indicadores sociodemográficos, institucionales, clínicos, de comunicación y apego a reglamentación vigente. RESULTADOS. Las inconformidades se originaron en el tercer trimestre de gestación (82.8%), en la seguridad social en 72.1%, en hospitales de 2º nivel (62.3%). La calificación de riesgo fue elevado en 57%, con cesárea previa como antecedente más frecuente (21.5%). Las complicaciones eran previsibles en casi la mitad de los casos. La principal desviación fue vigilancia deficiente del trabajo de parto (22.3%). Se identificó mala práctica en 54.5%, desviaciones éticas en 30%, deficiencias institucionales en 40.5%, expedientes mal integrados en 45% y mala comunicación en 76%. CONCLUSIONES. Una atención obstétrica adecuada requiere: compromiso y ética profesional, atención minuciosa, identificar los casos de riesgo, reconocer limitaciones personales e institucionales, conocer la normatividad y una comunicación médico-paciente efectiva. Se presentan 9 recomendaciones, dirigidas al personal médico y paramédico que atiende pacientes obstétricas

A low steady HBsAg seroprevalence is associated with a low incidence of HBV-related liver cirrhosis and hepatocellular carcinoma in Mexico: a systematic review

To address the relationship between hepatitis B virus (HBV) endemicity and HBV-related liver diseases in Mexico. Research literature reporting on HBsAg and antibody to hepatitis B core antigen (anti-HBc) prevalence in Mexican study groups were searched in NLM Gateway, PubMed, IMBIOMED, and others. Weighted mean prevalence (WMP) was calculated from the results of each study group. A total of 50 studies were analyzed. Three nationwide surveys revealed an HBsAg seroprevalence of less than 0.3%. Horizontal transmission of HBV infection occurred mainly by sexual activity and exposure to both contaminated surgical equipment and body fluids. High-risk groups exposed to these factors included healthcare workers, pregnant women, female sex workers, hemodialysis patients, and emergency department attendees with an HBsAg WMP ranging from 1.05% (95% confidence interval [CI], 0.68–1.43) to 14.3% (95% CI, 9.5–19.1). A higher prevalence of anti-HBc in adults than those younger than 20 years was associated with the main risk factors. Anti-HBc WMP ranged from 3.13% (95% CI, 3.01–3.24) in blood donors to 27.7% (95% CI, 21.6–33.9) in hemodialysis patients. A heterogeneous distribution of HBV infection was detected, mainly in native Mexican groups with a high anti-HBc WMP of 42.0% (95% CI, 39.5–44.3) but with a low HBsAg WMP of 2.9% (95% CI 2.08–3.75). Estimations of the Mexican population growth rate and main risk factors suggest that HBsAg seroprevalence has remained steady since 1974. A low HBsAg prevalence is related to the low incidence of HBV-related liver cirrhosis and hepatocellular carcinoma (HCC) previously reported in Mexico