Implanted body packer: nueva modalidad de transporte intracorporal de drogas

El transporte intracorporal de cuerpos extraños por personas (en inglés denominados body packers, en español en argot "mulos", "correos" o "culeros") en nuestro país constituye en España una conocida forma de contrabando de drogas ilegales en sujetos provenientes de América del Sur y África para su distribución en España y, debido a nuestra particular situación geográfica, como puerta de entrada para el resto de Europa1-3. La introducción de nuevas modalidades de sustancias (drogas en estado líquido) y el uso de múltiples métodos de transporte pueden dificultar notablemente su detección

A personalized intervention to prevent depression in primary care: cost-effectiveness study nested into a clustered randomized trial

Abstract Background: Depression is viewed as a major and increasing public health issue, as it causes high distress in the people experiencing it and considerable financial costs to society. Efforts are being made to reduce this burden by preventing depression. A critical component of this strategy is the ability to assess the individual level and profile of risk for the development of major depression. This paper presents the cost-effectiveness of a personalized intervention based on the risk of developing depression carried out in primary care, compared with usual care. Methods: Cost-effectiveness analyses are nested within a multicentre, clustered, randomized controlled trial of a personalized intervention to prevent depression. The study was carried out in 70 primary care centres from seven cities in Spain. Two general practitioners (GPs) were randomly sampled from those prepared to participate in each centre (i.e. 140 GPs), and 3326 participants consented and were eligible to participate. The intervention included the GP communicating to the patient his/her individual risk for depression and personal risk factors and the construction by both GPs and patients of a psychosocial programme tailored to prevent depression. In addition, GPs carried out measures to activate and empower the patients, who also received a leaflet about preventing depression. GPs were trained in a 10- to 15-h workshop. Costs were measured from a societal and National Health care perspective. Qualityadjustedlife years were assessed using the EuroQOL five dimensions questionnaire. The time horizon was 18 months.This work was supported by grants from the Spanish Ministry of Health, the Institute of Health Carlos III (ISCIII) and the European Regional Development Fund (ERDF) ’A way to build Europe’(grant references PS09/02272, PS09/02147, PS09/01095, PS09/00849 and PS09/00461); the Andalusian Council of Health (grant reference PI-0569-2010); the Spanish Network of Primary Care Research ’redIAPP’ (RD06/0018, RD12/0005/0001); the ’Aragón group’ (RD06/0018/0020, RD12/0005/0006); the ’Bizkaya group’ (RD06/0018/0018, RD12/0005/0010); the Castilla-León Group (RD06/0018/0027); the Mental Health (SJD) Barcelona Group (RD06/0018/0017, RD12/0005/0008); and the Mental-Health, Services and Primary Care (SAMSERAP) MálagaGroup (RD06/0018/0039, RD12/0005/0005)

Estudio prospectivo de intervención sobre la eficacia y seguridad de la hepatectomía derecha sin movilización y con maniobra de suspensión en pacientes con metástasis hepáticas de carcinoma colorrectal

[spa] ANTECEDENTES: La hepatectomía derecha (HD) vía anterior con maniobra de suspensión (AH) descrita inicialmente para la resección de hepatocarcinomas de gran tamaño, no ha sido comparada con la técnica convencional en pacientes con metástasis hepáticas de cáncer colorrectal. El objetivo de este estudio ha sido evaluar la aplicabilidad de esta técnica y sus resultados postoperatorios, comparándolos con la técnica convencional, en pacientes con metástasis hepáticas de carcinoma colorrectal (MHCCR). MATERIAL Y MÉTODOS: Estudio prospectivo observacional de intervención de los pacientes sometidos a una HD vía anterior con maniobra de suspensión por MHCCR entre el 2009 y el 2012 (Grupo AH). Descripción de la aplicabilidad y complicaciones específicas de la técnica. Para la evaluación de su influencia en la morbilidad y mortalidad postoperatoria, así como en la recidiva, se compara con un grupo control prospectivo que incluye los pacientes operados mediante técnica convencional en el periodo previo (Grupo Conv). Para reducir sesgos de selección y tratamiento se ha realizada un cálculo de los pacientes mediante el Propensity Score, obteniendo 33 pacientes en cada grupo. Se ha realizado un análisis multivariante mediante regresión logística para identificar variables predictivas de la evolución postoperatoria. RESULTADOS: Durante el periodo de estudio se intervinieron 275 pacientes por MHCCR, de los cuales 57 requirieron HD. Se inició la HD por vía anterior con maniobra de suspensión en 52 casos, siendo factible en 44 de ellos (85%). Una vez aplicado el Propensity Score no se obtuvieron diferencias en las características basales, características del tumor primario ni de las metástasis hepáticas entre grupos. Tampoco encontramos diferencias en el peso de la pieza, procedimientos quirúrgicos asociados, tiempo quirúrgico ni tiempo de isquemia. Ningún paciente del grupo AH presentó hemorragia mayor a 2l ni requirió más de 4 concentrados de hematíes respecto a 3 y 2casos respectivamente en el grupo convencional, aunque no estadísticamente significativo. La morbilidad fue comparable (AH: 42% vs Conv: 51% p= 0.46). La ascitis postoperatoria fue significativamente inferior en el grupo AH (AH: 18% vs Conv: 54%; p=0.002). ). La incidencia de insuficiencia hepática fue similar, sin embargo la mortalidad relacionada con insuficiencia hepática fue discretamente inferior en el grupo AH, sin resultados estadísticamente significativos. La estancia hospitalaria fue 2 días inferior en el grupo AH (AH: 10.9±5.7 vs Conv: 14.4±8.1; p=0.05). En el análisis multivariante solo la técnica quirúrgica resultó un factor protector para la aparición de ascitis. Tras un seguimiento mínimo de 2 años, la recidiva fue similar. La supervivencia actuarial (AH: 52% vs Conv: 68%, p=0.85) y libre de enfermedad (AH: 34% vs Conv: 33%, p=0.98) fue comparable entre ambos grupos. CONCLUSIONES: La HD vía anterior con maniobra de suspensión es una técnica segura y aplicable en pacientes con MHCCR. Su uso puede mejorar la evolución postoperatoria, reduciendo el riesgo de ascitis, hemorragia mayor y mortalidad relacionada con insuficiencia hepática. La mejora en la evolución postoperatoria conlleva a una disminución en la estancia hospitalaria. No se ha demostrado influencia en la recidiva.[eng] PURPOSE: To establish the role of the anterior approach with liver hanging maneuver for right hepatectomy in patients with colorectal liver metastases (CRLM). SUMMARY BACKGROUND DATA: The indications for hepatectomy in patients with CRLM are expanding. The liver remnant must be protected toavoid morbidity. METHODS: We prospectively enrolled all patients with the diagnosis of CRLM requiring right hepatectomy from 2009 to 2012. In all cases right hepatectomy with an anterior-hanging maneuver approach was attempted. We compared the group of patients who underwent this procedure with a group of patients who had previously undergone a conventional right hepatectomy. To minimize selection bias, propensity score matching was performed, based on baseline patient characteristics. RESULTS: A right hepatectomy was planned in 57 cases. The anterior-hanging approach was feasible in 85% of cases. Overall morbidity was similar. In-hospital mortality due to hepatic insufficiency was 2.3% in anterior-hanging group compared to 9% in the conventional group (p ¼ 0.30). The incidence of ascites was significantly greater in the conventional group (AH: 18% vs Conv: 54%; p ¼ 0.002), and hospital stay was longer (AH: 10.9 _ 5.7 vs Conv: 14.4 _8.1 days; p ¼ 0.05). Bilirubin levels were significantly lower in anterior-hanging group in day 1 and 3. There were no differences on recurrence nor survival. CONCLUSIONS: The anterior-hanging approach for right hepatectomy in patients with CRLM can be used safely with a high feasibility rate. Its use contributes to improve postoperative course

Evaluation of bariatric surgery patients at the emergency department of a tertiary referral hospital

Objective: To describe the profile of the bariatric surgery patients that were admitted to the Emergency Department (ED). Method: A retrospective review of the reasons why bariatric surgery patients go to our ED. We analyzed the first 30 days after the surgery. We evaluated the number and indications of admissions, the examinations ordered, and final diagnosis and destination of the patients. Results: From January 2010 to July 2012, 320 patients underwent bariatric surgery at our Institution. Fifty three patients (16.6 %) were admitted to the ED at leas t once. We found 58 admissions (1.1 admissions by patient). Patients who had duodenal switch and Roux-en-Y gastric bypass were the most representative (74 %). The main indications for admission were abdominal pain (50 %), and problems related to the surgical wounds (22.4 %). Blood test was the most performed examination (75.9 %). The most frequent final diagnosis was unspecific abdominal pain in 27 cases (46.6 %), and complications of the surgical wound in 10 patients (17.2 %). Nineteen patients (35.84 %) were admitted to the surgical ward from the ED, and 5 of them required surgical revision (9.4 %). Multivariate analyses showed that the type of surgery was the only predictor variable for the ED admission. Conclusions: Attending ED after bariatric surgery is not common, and less than a third of the patients required hospital admission. Just a small percentage of the examinations showed any pathological value. Readmission rate is very low. Surgical procedure is the only predictor for ED admission

A personalized intervention to prevent depression in primary care: cost-effectiveness study nested into a clustered randomized trial.

Depression is viewed as a major and increasing public health issue, as it causes high distress in the people experiencing it and considerable financial costs to society. Efforts are being made to reduce this burden by preventing depression. A critical component of this strategy is the ability to assess the individual level and profile of risk for the development of major depression. This paper presents the cost-effectiveness of a personalized intervention based on the risk of developing depression carried out in primary care, compared with usual care. Cost-effectiveness analyses are nested within a multicentre, clustered, randomized controlled trial of a personalized intervention to prevent depression. The study was carried out in 70 primary care centres from seven cities in Spain. Two general practitioners (GPs) were randomly sampled from those prepared to participate in each centre (i.e. 140 GPs), and 3326 participants consented and were eligible to participate. The intervention included the GP communicating to the patient his/her individual risk for depression and personal risk factors and the construction by both GPs and patients of a psychosocial programme tailored to prevent depression. In addition, GPs carried out measures to activate and empower the patients, who also received a leaflet about preventing depression. GPs were trained in a 10- to 15-h workshop. Costs were measured from a societal and National Health care perspective. Qualityadjustedlife years were assessed using the EuroQOL five dimensions questionnaire. The time horizon was 18 months. With a willingness-to-pay threshold of €10,000 (£8568) the probability of cost-effectiveness oscillated from 83% (societal perspective) to 89% (health perspective). If the threshold was increased to €30,000 (£25,704), the probability of being considered cost-effective was 94% (societal perspective) and 96%, respectively (health perspective). The sensitivity analysis confirmed these results. Compared with usual care, an intervention based on personal predictors of risk of depression implemented by GPs is a cost-effective strategy to prevent depression. This type of personalized intervention in primary care should be further developed and evaluated. ClinicalTrials.gov, NCT01151982. Registered on June 29, 2010