Design of an integrated management control model for the state social enterprise Bucaramanga Health Institute

La investigación planteada busca mediante la aplicación de la teoría y los conceptos básicos de control de gestión proponer al ISABU (Instituto de Salud de Bucaramanga), la implementación de un sistema integral de control que sirva de instrumento a los niveles gerenciales, para evaluar situaciones particulares en la institución, medir el impacto en la prestación de los servicios y la aceptación de los mismos por parte del usuario. El diseño de este sistema integrado de control de gestión generará indicadores de aspectos críticos del éxito institucional en busca de efícientizar el funcionamiento organizacional basándonos en la metodología científica, buscaremos la calidad como eje fundamental de coherencia con su misión y visión. La aplicación de un indicador en el proceso de gestión, es útil para cuantificar objetivos, planificar, explicar relaciones y comportamientos estructurales, tomar decisiones, coordinar actuaciones de áreas diferentes así como para el control mismo de la gestión, beneficios apreciables para cualquier institución.CAPITULO I 1. DEFINICIÓN DEL PROBLEMA 6 2. JUSTIFICACIÓN 6 3. OBJETIVOS 7 3.1 GENERAL 7 3.2 ESPECIFICOS 8 4. METODOLOGÍA 8 5. MARCO DE REFERENCIA 10 5.1 MARCO TEORICO 10 5.1.1 OBJETIVO CONTROL INTEGRADO DE GESTION 11 5.1.2 INDICADORES DE GESTION: DEFINICIÓN 11 5.1.3 OBJETIVOS DE LOS INDICADORES DE GESTION 12 5.1.4 CARACTERISTICAS DE LOS INDICADORES DE GESTION 12 5.1.5 LA MEDICION: DEFINICIÓN E IMPORTANCIA 19 5.1.6 ATRIBUTOS DE UNA BUENA MEDICION 21 6. RESEÑA HISTORICA DEL ISABU 24 7. PRESUPUESTO ISABU 28 8. POBLACIÓN OBJETO DE ATENCIÓN PRIMER NIVEL EN 30 BUCARAMANGA 9. MORBILIDAD EN LA UNIDAD OPERATIVA HOSPITAL LOCAL 31 DEL NORTE 9.1 MORBILIDAD EN CONSULTA EXTERNA MEDICINA GENERAL 31 9.2 MORBILIDAD EN URGENCIAS DE MEDICINA GENERAL 31 9.3 MORBILIDAD EN HOSPITALIZACION DE PEDIATRIA 32 9.4 MORBILIDAD EN HOSPITALIZACION ADULTOS 32 10. MISIÓN DEL ISABU 33 10.1 MISION ACTUAL DEL ISABU 33 10.2 MISION REDEFINIDA POR NUESTRO GRUPO 33 11. VISION DEL ISABU 34 11.1VISION ACTUAL DEL ISABU 34 11.2 VISION REDEFINIDA POR NUESTRO GRUPO 34 12. PRINCIPIOS CORPORATIVOS 34 13. RECURSOS TECNOLÓGICOS Y HUMANOS 35 14. PORTAFOLIO DE SERVICIOS UNIDAD OPERATIVA HOSPITAL 35 LOCAL DEL NORTE 15. ORGANIGRAMA 36 CAPITULO II 39 16. FICHAS TENICAS DE PROCESOS MEJORADOS EN LAS 39 UNIDADES FUNCIONALES DE LA UNIDAD OPERATIVA HOSPITAL LOCAL DEL NORTE 16.1 FICHA TÉCNICA CONSULTA EXTERNA 41 16.2 FICHA TÉCNICA URGENCIAS 16.2.1 FICHA TÉCNICA CONSULTA Y ATENCIÓN DE URGENCIAS 44 16.2.2 FICHA TÉCNICA URGENCIAS GINECO-OBSTETRICAS 47 16.3 FICHA TÉCNICA HOSPITALIZACION PEDIATRIA 51 16.4 FICHA TÉCNICA HOSPITALIZACION GINECO-OOBSTETRICIA 54 16.5 FICHA TÉCNICA PROGRAMACIÓN CIRUGÍA 55 16.6 FICHA TÉCNICA ATENCIÓN DE CIRUGIA 58 16.7 FICHA TÉCNICA PROMOCION Y PREVENCIÓN 61 16.8 FICHA TÉCNICA ENTREGA MEDICAMENTOS A USUARIOS 64 16.9 FICHA TÉCNICA TOMA Y PROCESAMIENTO DE MUESTRAS 67 16.10 FICHA TÉCNICA ESTUDIOS RADIOLÓGICOS 70 16.11 FICHA TÉCNICA ALMACEN 16.11.1 FICHA TÉCNICA ALMACEN COMPRAS DIRECTAS 73 16.11.2 FICHA TÉCNICA ALMACEN ENTREGA DE MERCANCÍAS 75 16.12 FICHA TÉCNICA FACTURACIÓN 77 CAPITULO III 17. FLUJOGRAMAS MEJORADOS PROCESOS 78 17.1 FLUJOGRAMA PROCESO MEJORADO DE ATENCIÓN EN 80 CONSULTA EXTERNA 17.2 FLUJOGRAMA PROCESO MEJORADO CONSULTA Y ATENCIÓN 81 EN URGENCIAS 17.2.1 FLUJOGRAMA PROCESO MEJORADO CONSULTA Y 81 ATENCIÓN URGENCIAS MEDICINA GENERAL 17.2.2 FLUJOGRMA PROCESO MEJORADO DE ATENCIÓN 83 EN URGENCIAS GINECO-OOBSTETRICAS Y SALA DE PARTOS 17.3 FLUJOGRAMA PROCESO MEJORADO HOSPITALIZACION PEDIATRIA 17.3.1 FLUJOGRAMA PROCESO MEJORADO HOSPITALIZACION 87 PEDIATRIA PROVENIENTE DE CONSULTA EXTERNA 17.3.2 FLUJOGRAMA PROCESO MEJORADO HOSPITALIZACION 89 PEDIATRIA PROVENIENTE DE URGENCIAS 17.4 FLUJOGRAMA PROCESO MEJORADO HOSPITALIZACION GINECO-OBSTETRICIA1 17.5 FLUJOGRAMA PROCESO MEJORADO PROGRAMACION 91 CIRUGÍA 17.6 FLUJOGRAMA PROCESO MEJORADO ATENCIÓN DE QX 94 17.7 FLUJOGRAMA PROCESO MEJORADO PROMOCION Y 96 PREVENCIÓN 17.8 FLUJOGRAMA PROCESO MEJORADO PROCESO DE ENTREGA 98 DE MEDICAMENTOS AL USUARIO 1 Este flujograma es idéntico al proceso de Hospitalización pediátrica ya referido. 17.9 FLUJOGRAMA PROCESO MEJORADO TOMA Y PROCESO DE MUESTRAS DE LABORATORIO 101 17.10 FLUJOGRAMA PROCESO MEJORADO TOMA DE RAYOS X 103 17.11 FLUJOGRAMA PROCESO MEJORADO ALMACEN 17.11.1 FLUJOGRAMA PROCESO MEJORADO COMPRAS DIRECTAS 106 17.11.2 FLUJOGRAMA PROCESO MEJORADO ENTREGA DE MERCANCÍAS 109 17.12 FLUJOGRAMA PROCESO DE FACTURACIÓN 110 CAPITULO IV 18. INSTRUMENTOS PARALA FORMULACION DE INDICADORES DE 111 GESTION 18.1 INSTRUMENTO PARA INDICADORES DE GESTION CONSULTA 114 EXTERNA MEDICINA GENERAL 18.2 INSTRUMENTO PARA INDICADORES DE GESTION URGENCIAS 18.2.1 INSTRUMENTO PARA INDICADORES DE GESTION 119 URGENCIAS MEDICINA GENERAL 18.2.2 INSTRUMENTO PARA INDICADORES DE GESTION 122 URGENCIAS GINECO-OBSTETRICAS 18.3 INSTRUMENTO PARA INDICADORES DE GESTION 125 HOSPITALIZACION PEDIATRIA 18.4 INSTRUMENTO PARA INDICADORES DE GESTION 127 GINECO-OBSTETRICIA 18.5 INSTRUMENTO PARA INDICADORES DE GESTION 129 PROGRAMACIÓN DE CIRUGÍAS 18.6 INSTRUMENTO PARA INDICADORES DE GESTION 132 ATENCIÓN DE CIRUGÍA. 18.7 INSTRUMENTO PARA INDICADORES DE GESTION PROMOCION Y PREVENCIÓN 18.8 INSTRUMENTO PARA INDICADORES DE GESTION FARMACIA 134 18.9 INSTRUMENTO PARA INDICADORES DE GESTION 138 LABORATORIO CLINICO 18.10 INSTRUENTO PARA INDICADORES DE GESTION RAYOS X 139 18.11 INSTRUMENTO PARA INDICADORES DE GESTION FACTURACIÓN 18.12 INSTRUMENTO PARA INDICADORES DE GESTION 140 ALMACEN RECOMENDACIONES 143 BIBLIOGRAFÍA 144EspecializaciónThe proposed research seeks through the application of theory and basic concepts of management control to propose to the ISABU (Health Institute of Bucaramanga), the implementation of a comprehensive control system that serves as a instrument at managerial levels, to evaluate particular situations in the institution, measure the impact on the provision of services and the acceptance of the same by the user. The design of this integrated management control system will generate indicators of critical aspects of institutional success in search of efficient operation organization based on scientific methodology, we will seek the quality as a fundamental axis of coherence with its mission and vision. The application of an indicator in the management process is useful to quantify objectives, planning, explaining relationships and structural behaviors, taking decisions, coordinate actions of different areas as well as for the control same management, appreciable benefits for any institution

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019 : a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Background: Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods: 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings: The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66–2·79) in 2000 to 2·31 (2·17–2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5–137·8) in 2000 to a peak of 139·6 million (133·0–146·9) in 2016. Global livebirths then declined to 135·3 million (127·2–144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4–27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8–67·6) in 2000 to 73·5 years (72·8–74·3) in 2019. The total number of deaths increased from 50·7 million (49·5–51·9) in 2000 to 56·5 million (53·7–59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1–10·3) in 2000 to 5·0 million (4·3–6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0–6·3) in 2000 to 7·7 billion (7·5–8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1–60·8) in 2000 to 63·5 years (60·8–66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019

Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

How long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years. Methods We used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males. Findings Globally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1-7·8), from 65·6 years (65·3-65·8) in 1990 to 73·0 years (72·7-73·3) in 2017. The increase in years of life varied from 5·1 years (5·0-5·3) in high SDI countries to 12·0 years (11·3-12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1-33·1) were expected to be spent in poor health in high SDI countries compared with 11·7% (8·8-15·1) in low-middle SDI countries. HALE at birth increased by 6·3 years (5·9-6·7), from 57·0 years (54·6-59·1) in 1990 to 63·3 years (60·5-65·7) in 2017. The increase varied from 3·8 years (3·4-4·1) in high SDI countries to 10·5 years (9·8-11·2) in low SDI countries. Even larger variations in HALE than these were observed between countries, ranging from 1·0 year (0·4-1·7) in Saint Vincent and the Grenadines (62·4 years [59·9-64·7] in 1990 to 63·5 years [60·9-65·8] in 2017) to 23·7 years (21·9-25·6) in Eritrea (30·7 years [28·9-32·2] in 1990 to 54·4 years [51·5-57·1] in 2017). In most countries, the increase in HALE was smaller than the increase in overall life expectancy, indicating more years lived in poor health. In 180 of 195 countries and territories, females were expected to live longer than males in 2017, with extra years lived varying from 1·4 years (0·6-2·3) in Algeria to 11·9 years (10·9-12·9) in Ukraine. Of the extra years gained, the proportion spent in poor health varied largely across countries, with less than 20% of additional years spent in poor health in Bosnia and Herzegovina, Burundi, and Slovakia, whereas in Bahrain all the extra years were spent in poor health. In 2017, the highest estimate of HALE at birth was in Singapore for both females (75·8 years [72·4-78·7]) and males (72·6 years [69·8-75·0]) and the lowest estimates were in Central African Republic (47·0 years [43·7-50·2] for females and 42·8 years [40·1-45·6] for males). Globally, in 2017, the five leading causes of DALYs were neonatal disorders, ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive pulmonary disease. Between 1990 and 2017, age-standardised DALY rates decreased by 41·3% (38·8-43·5) for communicable diseases and by 49·8% (47·9-51·6) for neonatal disorders. For non-communicable diseases, global DALYs increased by 40·1% (36·8-43·0), although age-standardised DALY rates decreased by 18·1% (16·0-20·2)

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

How long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years.; We used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males. Globally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1-7·8), from 65·6 years (65·3-65·8) in 1990 to 73·0 years (72·7-73·3) in 2017. The increase in years of life varied from 5·1 years (5·0-5·3) in high SDI countries to 12·0 years (11·3-12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1-33·1) were expected to be spent in poor health in high SDI countries compared with 11·7% (8·8-15·1) in low-middle SDI countries. HALE at birth increased by 6·3 years (5·9-6·7), from 57·0 years (54·6-59·1) in 1990 to 63·3 years (60·5-65·7) in 2017. The increase varied from 3·8 years (3·4-4·1) in high SDI countries to 10·5 years (9·8-11·2) in low SDI countries. Even larger variations in HALE than these were observed between countries, ranging from 1·0 year (0·4-1·7) in Saint Vincent and the Grenadines (62·4 years [59·9-64·7] in 1990 to 63·5 years [60·9-65·8] in 2017) to 23·7 years (21·9-25·6) in Eritrea (30·7 years [28·9-32·2] in 1990 to 54·4 years [51·5-57·1] in 2017). In most countries, the increase in HALE was smaller than the increase in overall life expectancy, indicating more years lived in poor health. In 180 of 195 countries and territories, females were expected to live longer than males in 2017, with extra years lived varying from 1·4 years (0·6-2·3) in Algeria to 11·9 years (10·9-12·9) in Ukraine. Of the extra years gained, the proportion spent in poor health varied largely across countries, with less than 20% of additional years spent in poor health in Bosnia and Herzegovina, Burundi, and Slovakia, whereas in Bahrain all the extra years were spent in poor health. In 2017, the highest estimate of HALE at birth was in Singapore for both females (75·8 years [72·4-78·7]) and males (72·6 years [69·8-75·0]) and the lowest estimates were in Central African Republic (47·0 years [43·7-50·2] for females and 42·8 years [40·1-45·6] for males). Globally, in 2017, the five leading causes of DALYs were neonatal disorders, ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive pulmonary disease. Between 1990 and 2017, age-standardised DALY rates decreased by 41·3% (38·8-43·5) for communicable diseases and by 49·8% (47·9-51·6) for neonatal disorders. For non-communicable diseases, global DALYs increased by 40·1% (36·8-43·0), although age-standardised DALY rates decreased by 18·1% (16·0-20·2). With increasing life expectancy in most countries, the question of whether the additional years of life gained are spent in good health or poor health has been increasingly relevant because of the potential policy implications, such as health-care provisions and extending retirement ages. In some locations, a large proportion of those additional years are spent in poor health. Large inequalities in HALE and disease burden exist across countries in different SDI quintiles and between sexes. The burden of disabling conditions has serious implications for health system planning and health-related expenditures. Despite the progress made in reducing the burden of communicable diseases and neonatal disorders in low SDI countries, the speed of this progress could be increased by scaling up proven interventions. The global trends among non-communicable diseases indicate that more effort is needed to maximise HALE, such as risk prevention and attention to upstream determinants of health

INFECCIONES OPORTUNISTAS COMO CAUSA DE MUERTE EN PACIENTES CON ENFERMEDAD AUTOINMUNE. UN ESTUDIO DE AUTOPSIAS

Introducción y objetivo: Los pacientes con enfermedades autoinmunes puede desarrollar infecciones oportunistas potencialmente mortales y de difícil diagnóstico. En este trabajo se presentan los resultados de autopsias realizadas en pacientes que recibieron tratamiento inmunosupresor y fallecen a causa de dichos procesos infecciosos. Métodos: Se analizaron 1441 protocolos de autopsias realizadas en el Departamento de Patología de la Universidad Industrial de Santander (UIS) a individuos fallecidos en Bucaramanga, entre enero de 2010 y diciembre de 2014. Resultados: Se encontraron 13 casos de pacientes con enfermedad autoinmune, de los cuales 4 fallecieron a consecuencia de una infección oportunista. Estos 4 pacientes se encontraban entre los 32 y 43 años de edad. Todos los pacientes se encontraban bajo tratamiento inmunosupresor y posteriormente fallecen por infección oportunista no sospechada durante su estancia hospitalaria. Dos de ellos (2/4) presentaban lupus eritematoso sistémico y en ellos se encontró toxoplasmosis encefálica, criptococosis pulmonar y tuberculosis diseminada. En un paciente con artritis reumatoide (1/4) el hallazgo fue tuberculosis secundaria de reactivación con compromiso de encéfalo, meninges, pulmones y riñones. Finalmente un paciente con dermatomiositis (1/4) falleció a causa de perforación intestinal por citomegalovirus con peritonitis, neumonitis intersticial por el mismo germen, tuberculosis pulmonar y neumonía por Acinetobacter. Conclusiones: En personas con enfermedades autoinmunes que reciben cualquier terapia inmunosupresora es importante realizar un tamizaje completo que incluya serología para microorganismos oportunistas. Además se debe contemplar como diagnóstico diferencial la reactivación de estas infecciones, pues pueden ser rápidamente mortales

Enfermedad de Chagas: correlación clínico-patológica. Serie de casos del Hospital Universitario de Santander - Departamento de Patología, Universidad Industrial de Santander Chagas disease: clinicopathologic correlation. Series of cases of the University Hospital of Santander - Department of Pathology, Universidad Industrial de Santander

La enfermedad de Chagas es un padecimiento que predomina en aquellas regiones del continente americano que combinan condiciones geográficas, climáticas y ecológicas para que el hombre, el Trypanosoma cruzi, sus reservorios y vectores, interactúen de manera ideal. Objetivo: presentar nueve casos de enfermedad de Chagas diagnosticados mediante autopsia en el Departamento de Patología de la Universidad Industrial de Santander entre 2002 y 2009, correlacionar los hallazgos pos-mortem con las manifestaciones clínicas y comparar los datos obtenidos con la información referida en la literatura mundial. Materiales y Métodos: estudio descriptivo, retrospectivo en casos de autopsias realizadas en el Departamento de Patología de la Universidad Industrial de Santander entre el primero de enero de 2002 y el 30 de junio de 2009. Resultados: de un total de 756 autopsias, nueve (1,2%) correspondieron a pacientes con diagnóstico confirmado de enfermedad de Chagas: siete hombres y dos mujeres. El rango de edad osciló entre 14 meses y 56 años. De los casos analizados cinco correspondieron a la forma aguda, dos a la forma crónica y dos a un proceso de reactivación. Todos tenían compromiso cardíaco, uno compromiso del colon y uno compromiso encefálico. La causa de muerte se relacionó de manera directa con estas afecciones. Conclusión: en zonas endémicas, ante la presencia de manifestaciones cardíacas, es necesario considerar la enfermedad de Chagas con el fin de realizar un diagnóstico precoz y oportuno que permita identificar casos y establecer medidas de manejo específico enfocado de acuerdo con su condición.<br>Chagas disease is a condition that prevails in those regions of the Americas that combine geographical, climatic and ecological conditions so that man,Trypanosoma cruzi, their reservoirs and vectors may ideally interact. Objective: to present nine cases of Chagas disease diagnosed by autopsy at the Department of Pathology, Universidad Industrial de Santander between 2002 and 2009, correlating post-mortem findings with the clinical manifestations, and compare these data with the information referred in the world literature. Materials and Methods: a descriptive, retrospective study of autopsy cases performed in the Department of Pathology, Universidad Industrial de Santander between January 2002 and June 30, 2009. Results: of a total of 756 autopsies, nine (1.2%) were patients with confirmed diagnosis of Chagas disease: seven men and two women. The age range oscillated between 14 months and 56 years. Of the cases analyzed, five corresponded to the acute form, two to the chronic form, and two to a process of reactivation. All had cardiac involvement; one had colon involvement, and one brain involvement. The cause of death was directly related to these conditions. Conclusion: in the presence of cardiac manifestations in endemic areas, is necessary to consider Chagas disease, in order to make an early and appropriate diagnosis, to identify cases and to establish specific management measures focused according to their condition