Reflexiones: ¿El maltrato es un problema de salud?

El concepto de problema de salud no se limita a una enfermedad en particular, no exige un nivel de daño o deterioro de la salud, sino, al menos, una preocupación del médico o del paciente de que pueda afectarse la salud por ese problema. El Maltrato y la Violencia familiar es un problema que daña mucho la salud, sobre todo, de los niños, mujeres y ancianos. En nuestra práctica diaria, podemos ver algunos casos en que algún miembro de la familia, fundamentalmente, niños o ancianos son maltratados, y por el desconocimiento de que estos hechos están contemplados en la Décima Revisión de la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud , los médicos, enfermeras y profesionales de la Atención Primaria y de la Salud en general no adoptamos acciones administrativas como el informe en los registros primarios y no aparece como un problema de salud, estadísticamente hablando. En este trabajo, se reflexiona sobre este hecho con el objetivo de dejar claro que el Maltrato es un problema de salud, no por el hecho de que exista el fenómeno en sí, sino porque, además, está reconocido como tal por la OMS (CIE 10) y podemos manejarlo como los otros problemas de salud y resolverlo con mayor facilidad aunando los nuestros esfuerzos y experiencias para evitar su perpetuidad, su recurrencia y sus consecuencias.</p

Alfafeto proteína en suero materno elevada: Relación con el bajo peso al nacer. Estudio comparativo

Se realiza estudio de serie cronológica de los nacidos vivos con bajo peso durante 1990–1993 y 2000–2003, comparándose entre ambos períodos la sensibilidad y valor predictivo positivo de la Alfafeto proteína en suero materno elevada, con el objetivo de comprobar su utilidad como indicador de riesgo de bajo peso al nacer en ausencia de defectos de cierre del tubo neural en el Policlínico Docente Rampa del municipio Plaza de Ciudad de La Habana. Se determinó una sensibilidad de 15,68% y 11,94% y un valor predictivo positivo de 30,76% y 24%, respectivamente, independiente de la natalidad e índice de bajo peso de ambos períodos.Palabras clave : Alfafeto proteína, bajo peso al nacer, valor predictivo, indicador de riesgo. </h2

REFLEXIONES: ¿EL MALTRATO ES UN PROBLEMA DE SALUD?

El concepto de problema de salud no se limita a una enfermedad en particular, no exige un nivel de daño o deterioro de la salud, sino, al menos, una preocupación del médico o del paciente de que pueda afectarse la salud por ese problema. El Maltrato y la Violencia familiar es un problema que daña mucho la salud, sobre todo, de los niños, mujeres y ancianos. En nuestra práctica diaria, podemos ver algunos casos en que algún miembro de la familia, fundamentalmente, niños o ancianos son maltratados, y por el desconocimiento de que estos hechos están contemplados en la Décima Revisión de la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud , los médicos, enfermeras y profesionales de la Atención Primaria y de la Salud en general no adoptamos acciones administrativas como el informe en los registros primarios y no aparece como un problema de salud, estadísticamente hablando. En este trabajo, se reflexiona sobre este hecho con el objetivo de dejar claro que el Maltrato es un problema de salud, no por el hecho de que exista el fenómeno en sí, sino porque, además, está reconocido como tal por la OMS (CIE 10) y podemos manejarlo como los otros problemas de salud y resolverlo con mayor facilidad aunando los nuestros esfuerzos y experiencias para evitar su perpetuidad, su recurrencia y sus consecuencias

Clinical manifestations of intermediate allele carriers in Huntington disease

Objective: There is controversy about the clinical consequences of intermediate alleles (IAs) in Huntington disease (HD). The main objective of this study was to establish the clinical manifestations of IA carriers for a prospective, international, European HD registry. Methods: We assessed a cohort of participants at risk with <36 CAG repeats of the huntingtin (HTT) gene. Outcome measures were the Unified Huntington's Disease Rating Scale (UHDRS) motor, cognitive, and behavior domains, Total Functional Capacity (TFC), and quality of life (Short Form-36 [SF-36]). This cohort was subdivided into IA carriers (27-35 CAG) and controls (<27 CAG) and younger vs older participants. IA carriers and controls were compared for sociodemographic, environmental, and outcome measures. We used regression analysis to estimate the association of age and CAG repeats on the UHDRS scores. Results: Of 12,190 participants, 657 (5.38%) with <36 CAG repeats were identified: 76 IA carriers (11.56%) and 581 controls (88.44%). After correcting for multiple comparisons, at baseline, we found no significant differences between IA carriers and controls for total UHDRS motor, SF-36, behavioral, cognitive, or TFC scores. However, older participants with IAs had higher chorea scores compared to controls (p 0.001). Linear regression analysis showed that aging was the most contributing factor to increased UHDRS motor scores (p 0.002). On the other hand, 1-year follow-up data analysis showed IA carriers had greater cognitive decline compared to controls (p 0.002). Conclusions: Although aging worsened the UHDRS scores independently of the genetic status, IAs might confer a late-onset abnormal motor and cognitive phenotype. These results might have important implications for genetic counseling. ClinicalTrials.gov identifier: NCT01590589

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research

Clinical and genetic characteristics of late-onset Huntington's disease

Background: The frequency of late-onset Huntington's disease (&gt;59 years) is assumed to be low and the clinical course milder. However, previous literature on late-onset disease is scarce and inconclusive. Objective: Our aim is to study clinical characteristics of late-onset compared to common-onset HD patients in a large cohort of HD patients from the Registry database. Methods: Participants with late- and common-onset (30–50 years)were compared for first clinical symptoms, disease progression, CAG repeat size and family history. Participants with a missing CAG repeat size, a repeat size of ≤35 or a UHDRS motor score of ≤5 were excluded. Results: Of 6007 eligible participants, 687 had late-onset (11.4%) and 3216 (53.5%) common-onset HD. Late-onset (n = 577) had significantly more gait and balance problems as first symptom compared to common-onset (n = 2408) (P &lt;.001). Overall motor and cognitive performance (P &lt;.001) were worse, however only disease motor progression was slower (coefficient, −0.58; SE 0.16; P &lt;.001) compared to the common-onset group. Repeat size was significantly lower in the late-onset (n = 40.8; SD 1.6) compared to common-onset (n = 44.4; SD 2.8) (P &lt;.001). Fewer late-onset patients (n = 451) had a positive family history compared to common-onset (n = 2940) (P &lt;.001). Conclusions: Late-onset patients present more frequently with gait and balance problems as first symptom, and disease progression is not milder compared to common-onset HD patients apart from motor progression. The family history is likely to be negative, which might make diagnosing HD more difficult in this population. However, the balance and gait problems might be helpful in diagnosing HD in elderly patients