Evidences in the treatment of idiopathic normal pressure hydrocephalus

Summary Introduction: idiopathic normal pressure hydrocephalus (INPH) is characterized by gait apraxia, cognitive dysfunction and urinary incontinence. There are two main treatment options: ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV). However, there are doubts about which modality is superior and what type of valve should be applied. We are summarizing the current evidence in INPH treatment. Methods: an electronic search of the literature was conducted on the Medline, Embase, Scielo and Lilacs databases from 1966 to the present to obtain data published about INPH treatment. Results: the treatment is based on three pillars: conservative, ETV and VPS. The conservative option has fallen into disuse after various studies showing good results after surgical intervention. ETV is an acceptable mode of treatment, but the superiority of VPS has made the latter the gold standard. Conclusion: well-designed studies with a high level of appropriate evidence are still scarce, but the current gold standard for treatment of INPH is conducted using VPS.</jats:p

Adoption and asessment of innovative health technologies within the Brazilian health care system: a case study in cardiology

Introdução: Amplo debate tem associado a incorporação de novas tecnologias para a saúde com os custos crescentes dos sistemas de saúde. Face à dúvidas \"se as novas tecnologias são parte do problema, parte da solução ou as duas coisas\" relativamente à saúde da população e do sistema de saúde, este estudo de caso analisa a incorporação de três inovações no Instituto do Coração, InCor-HC/FMUSP, visando elaborar quais fatores influenciaram a decisão de adoção e exemplificar as metodologias de avaliação de novo medicamento, de procedimento diagnóstico e intervenção cirúrgica. A avaliação das tecnologias para a saúde, ATS, pode auxiliar a constituir algumas propostas de respostas. Metodologia: estudo qualitativo empírico em caso retrospectivo de incorporação de três inovações para assistência de alta complexidade em cardiologia. As metodologias utilizadas consistiram em entrevistas aos tomadores de decisão, revisões sistemáticas da literatura relevante, descritiva ou meta-analítica, e análise de impacto econômico hospitalar. Resultados: O padrão do InCor para a incorporação das inovações funciona como um sistema social criativo, sob uma estratégia prática pluralista, ou seja, utilizam as pesquisas, aprovadas pela Comissão de Ética e Pesquisa do InCor e do HC, que se sucederam e que sucedem em incrementos, verificando e ajustando as informações segundo os resultados obtidos para desenhar novas pesquisas. Os atores construíram conhecimentos e negociaram protocolos de pesquisa, promoveram a capacitação de super-especialistas técnicos, transferindo práticas internacionais e gerando conhecimentos adaptados à realidade do Brasil. A avaliação do medicamento tacrolimus demonstra que se poderia resgatar uma média de 75% das rejeições refratárias às terapias convencionais, proporcionando um custo hospitalar de R$R$ 102,99 por dia de sobrevida nos 8 adultos e R$137,53 nas 13 crianças observadas, comparativamente à R$ 229,00 e R$260,00, com ciclosporina, respectivamente. Assim, se evitaria 37$45 or R$102.99 per day of survival in 8 adults and of US$61 or R$137.53 for the 13 children (<18 years of age), compared with R$ 229.00 and R$ 260.00, respectively, in those who remained under cyclosporine treatment. Thus, it could prevent 37% rejection related mortality and bring some economy (even in the single child death observed, the hospital cost per day until death was the half of the cost observed for the 32 cyclosporine treated). - The tomoangiocoronariography diagnosis for patients presenting atypical angina and moderate to low risk of stenosis may orient and modify up to 66% clinical decisions preventing requirement of an invasive procedure. This would increase 20% to the Haemodynamic Department 25% resolutivity, may prevent up to 2000 deaths with an estimated additional 10% of the costs of 14% more angioplasties and 6% increase in surgical coronary bypasses for the health care system. - Surgical ablation has the potential to cure more than 10% of medications refractory atrial fibrillation in patients undergoing open heart surgery for structural corrections. Supposing it is restricted only to the group of patients undergoing valve surgery in the health care system, it could prevent morbidity and mortality for up to 1000 patients. Conclusions and discussion: The new technologies evaluated bring benefits to the health of the patients. Safety concerns and economic impact for the InCor and for the health care system assistance programs require further investigation. InCor and the other university hospitals have enhanced technical capacity installed. The structured research facilitates and allows incorporation of highly complex innovations without planning future programs for care. The isolation of these decision makers from the health care system decision planners allows partial views and immediacies. Such a distance facilitates development of external and diverse interests. These facts, consequently, pressures on the organization and the health care system. The integration of the university hospitals installed professional capacities, within an average and long term health care system plans, making evaluations of the innovative health technologies in comparison with the established ones based on local epidemiology, may permit a planned and continuous actualization of the health services on solid scientific basis adapted to the Brazilian reality and with a responsible financial balance

Financial Impact of Deep Sternal Wound Infections After Coronary Surgery: A Microcosting Analysis

ABSTRACT Introduction: Deep sternal wound infections (DSWI) are so serious and costly that hospital services continue to strive to control and prevent these outcomes. Microcosting is the more accurate approach in economic healthcare evaluation, but there are no studies in this field applying this method to compare DSWI after isolated coronary artery bypass grafting (CABG). This study aims to evaluate the incremental risk-adjusted costs of DSWI on isolated CABG. Methods: This is a retrospective, single-center observational cohort study with a propensity score matching for infected and non-infected patients to compare incremental risk-adjusted costs between groups. Data to homogeneity sample was obtained from a multicentric database, REPLICCAR II, and additional sources of information about costs were achieved with the electronic hospital system (Si3). Inflation variation and dollar quotation in the study period were corrected using the General Market Price Index. Groups were compared using analysis of variance, and multiple linear regression was performed to evaluate the cost drivers related to the event. Results: As expected, infections were costly; deep infection increased the costs by 152% and mediastinitis by 188%. Groups differed among hospital stay, exams, medications, and multidisciplinary labor, and hospital stay costs were the most critical cost driver. Conclusion: In summary, our results demonstrate the incremental costs of a detailed microcosting evaluation of infections on CABG patients in São Paulo, Brazil. Hospital stay was an important cost driver identified, demonstrating the importance of evaluating patients’ characteristics and managing risks for a faster, safer, and more effective discharge

Artroplastia reversa do ombro: avaliação dos resultados clínicos e da qualidade de vida

ResumoObjetivoAvaliar os resultados clínicos e radiológicos e o impacto na qualidade de vida da artroplastia reversa do ombro.MétodosSérie de casos retrospectiva que avaliou 13 pacientes submetidos à artroplastia reversa do ombro com seguimento clínico mínimo de dois anos. Foi feita avaliação clínica antes e após a cirurgia com as escalas da American Shoulder and Elbow Surgeons (ASES) e escala visual analógica (EVA) e as manobras funcionais mão‐boca, mão‐nuca e mão‐cabeça. A qualidade de vida foi aferida com o questionário 12‐Item Short‐Form Health Survey (SF‐12). Registramos o índice de complicações e o aspecto radiográfico pós‐operatório.ResultadosOs pacientes evoluíram de 23,1±15 para 82,7±15 pela escala da ASES (p < 0,001). O componente físico do SF‐12 passou de 31,7±6,9 para 47,1±8,6 (p<0,001) enquanto o emocional de 48±12,3 para 55,5±7,5 (p=0,061). A dor regrediu de 7,9 para 1 de acordo com a EVA (p=0,002). As manobras funcionais mão‐boca, mão‐nuca e mão‐cabeça apresentaram melhorias significativas (p=0,039, p<0,001 e p<0,001, respectivamente). Complicações ocorreram em 15% dos pacientes e notching, em 31%.ConclusãoOs pacientes submetidos à artroplastia reversa do ombro tiveram melhoria significativa de acordo com as escalas da ASES e EVA. A qualidade de vida melhorou significativamente de acordo com o aspecto físico do SF‐12 e demonstrou tendência de melhoria no aspecto emocional. O índice de complicações foi de 15% e notching ocorreu em 31%.AbstractObjectiveTo evaluate the clinical and radiological results and the impact on quality of life of the reverse shoulder arthroplasty.MethodsRetrospective case series evaluating 13 patients undergoing reverse shoulder arthroplasty with at least two years of clinical follow‐up. Clinical evaluation was performed before and after surgery with the ASES and VAS scales and hand‐mouth, hand‐neck, and hand‐head functional tests. Quality of life was measured with the SF‐12 questionnaire. The rate of complications and radiographic postoperative findings were recorded.ResultsThe patients improved from 23.1±15 to 82.7±15 according to ASES scale (p<0.001). The physical component of the SF‐12 increased from 31.7±6.9 to 47.1±8.6 (p<0.001), while the emotional increased from 48±12.3 to 55.5±7.5 (p=0.061). The pain reduced from 7.9 to 1 according to the VAS (p=0.002). The performance on the hand‐mouth, hand‐neck, and hand‐head functional tests showed significant improvement (p=0.039, p<0.001 and p<0.001, respectively). Complications occurred in 15% of patients and notching, in 31%.ConclusionReverse shoulder arthroplasty led to a significant clinical improvement according to the ASES and VAS scales. The quality of life has improved according to the physical aspect of the SF‐12, and showed a trend of improvement in the emotional aspect. The complication rate was 15%, and notching occurred in 31%

Reverse shoulder arthroplasty: clinical results and quality of life evaluation

ABSTRACT OBJECTIVE: To evaluate the clinical and radiological results and the impact on quality of life of the reverse shoulder arthroplasty. METHODS: Retrospective case series evaluating 13 patients undergoing reverse shoulder arthroplasty with at least two years of clinical follow-up. Clinical evaluation was performed before and after surgery with the ASES and VAS scales and hand-mouth, hand-neck, and hand-head functional tests. Quality of life was measured with the SF-12 questionnaire. The rate of complications and radiographic postoperative findings were recorded. RESULTS: The patients improved from 23.1 ± 15 to 82.7 ± 15 according to ASES scale (p < 0.001). The physical component of the SF-12 increased from 31.7 ± 6.9 to 47.1 ± 8.6 (p < 0.001), while the emotional increased from 48 ± 12.3 to 55.5 ± 7.5 (p = 0.061). The pain reduced from 7.9 to 1 according to the VAS (p = 0.002). The performance on the hand-mouth, hand-neck, and hand-head functional tests showed significant improvement (p = 0.039, p < 0.001 and p < 0.001, respectively). Complications occurred in 15% of patients and notching, in 31%. CONCLUSION: Reverse shoulder arthroplasty led to a significant clinical improvement according to the ASES and VAS scales. The quality of life has improved according to the physical aspect of the SF-12, and showed a trend of improvement in the emotional aspect. The complication rate was 15%, and notching occurred in 31%

Eltrombopag for Adults and Children with Immune-Refractory Thrombocytopenic Purpura: A Systematic Review

Eltrombopag is an agonist that binds to the membrane-bound domain of the thrombopoietin receptor used in immune thrombocytopenic purpura (ITP). We conducted a meta-analysis of randomized controlled trials to assess the efficacy and safety of eltrombopag in adults and children with refractory ITP. Adults who received eltrombopag had a significantly better platelet response (relative risk [RR], 3.65; 95% confidence interval [CI], 2.39&ndash;5.55), but there were no differences in the incidence of bleeding (RR, 0.8; 95% CI, 0.52&ndash;1.22) and adverse effects (RR, 0.99; 95% CI, 0.55&ndash;1.78) compared with the placebo. In children, there was no difference between eltrombopag and placebo for a platelet response &gt;50,000/mm3 (RR, 3.93; 95% CI, 0.56&ndash;27.79) and the number of adverse events (RR, 0.99; 95% CI, 0.25&ndash;1.49); however, a lower incidence of bleeding was observed (RR, 0.47; 95% CI, 0.27&ndash;0.83). Treatment with eltrombopag protected adults and children from severe disease and death