Cáncer gástrico en pacientes de Méderi – Hospital Universitario Mayor entre los años 2011 - 2014

Introducción: El cáncer gástrico es uno de los más frecuentes a nivel mundial y Colombia se sitúa entre los países de mayor incidencia en este tipo de patología. Objetivo: Describir las características epidemiológicas, clínicas, el tratamiento administrado y los desenlaces inmediatos de los pacientes con diagnóstico de cáncer gástrico atendidos en el Hospital Universitario Mayor de Bogotá entre los años 2011 y 2014. Metodología: Se realizó un estudio observacional descriptivo con diagnóstico de cáncer gástrico. Se realizaron análisis univariados por medio de proporciones para las variables cualitativas y medidas de tendencia central para las variables cuantitativas según la distribución. Resultados: Un total de 189 pacientes fueron analizados. El dolor fue el síntoma más frecuente en los pacientes (30.7%) y el principal signo encontrado fue una masa palpable en abdomen (9,5%). Los pacientes fueron sometidos a diferentes abordajes terapéuticos, la mayoría recibieron manejo paliativo no quirúrgico (52.9%) y la opción quirúrgica más usada en los pacientes fue la gastrectomía total (20.6%), y la subtotal (16,4) seguidas de quimioterapia y/o radiación perioperatoria. Los pacientes que sobrevivieron a los 2 años fueron 7,4% del total. Conclusiones: El registro de los pacientes con cáncer gástrico es bueno en el Méderi-Hospital Universitario Mayor es bueno y permite caracterizar los pacientes, la presentación de la patología y los resultados del tratamiento que concuerdan con los presentados en contextos similares en la literatura.

Multi-Principal Agency and the Compliance with Professional Guidelines in Health Systems: Economic and Regulatory Perspectives

Amid the trend of rising health expenditure in developed economies, changing the healthcare delivery models is an important point of action for service regulators to contain this trend. Such a change is mostly induced by either financial incentives or regulatory tools issued by the regulators and targeting service providers and patients. This creates a tripartite interaction between service regulators, professionals, and patients that manifests a multi-principal agent relationship, in which professionals are agents to two principals: regulators and patients. This thesis is concerned with such a multi-principal agent relationship in healthcare and attempts to investigate the determinants of the (non-)compliance to regulatory tools in light of this tripartite relationship. In addition, the thesis provides insights into the different institutional, economic, and regulatory settings, which govern the multi-principal agent relationship in healthcare in different countries. Furthermore, the thesis provides and empirically tests a conceptual framework of the possible determinants of (non-)compliance by physicians to regulatory tools issued by the regulator. The main findings of the thesis are first, in a multi-principal agent setting, the utilization of financial incentives to align the objectives of professionals and the regulator is important but not the only solution. This finding is based on the heterogeneity in the financial incentives provided to professionals in different health markets, which does not provide a one-size-fits-all model of financial incentives to influence clinical decisions. Second, soft law tools as clinical practice guidelines (CPGs) are important tools to mitigate the problems of the multi-principal agent setting in health markets as they reduce information asymmetries while preserving the autonomy of professionals. Third, CPGs are complex and heterogeneous and so are the determinants of (non-)compliance to them. Fourth, CPGs work but under conditions. Factors such as intra-professional competition between service providers or practitioners might lead to non-compliance to CPGs – if CPGs are likely to reduce the professional’s utility. Finally, different degrees of soft law mandate have different effects on providers’ compliance. Generally, the stronger the mandate, the stronger the compliance, however, even with a strong mandate, drivers such as intra-professional competition and co-management of patients by different professionals affected the (non-)compliance.

The Value Of The 2005 International Society Of Urological Pathology (isup) Modified Gleason Grading System As A Predictor Of Biochemical Recurrence After Radical Prostatectomy.

To compare time and risk to biochemical recurrence (BR) after radical prostatectomy of two chronologically different groups of patients using the standard and the modified Gleason system (MGS). Cohort 1 comprised biopsies of 197 patients graded according to the standard Gleason system (SGS) in the period 1997/2004, and cohort 2, 176 biopsies graded according to the modified system in the period 2005/2011. Time to BR was analyzed with the Kaplan-Meier product-limit analysis and prediction of shorter time to recurrence using univariate and multivariate Cox proportional hazards model. Patients in cohort 2 reflected time-related changes: striking increase in clinical stage T1c, systematic use of extended biopsies, and lower percentage of total length of cancer in millimeter in all cores. The MGS used in cohort 2 showed fewer biopsies with Gleason score ≤ 6 and more biopsies of the intermediate Gleason score 7. Time to BR using the Kaplan-Meier curves showed statistical significance using the MGS in cohort 2, but not the SGS in cohort 1. Only the MGS predicted shorter time to BR on univariate analysis and on multivariate analysis was an independent predictor. The results favor that the 2005 International Society of Urological Pathology modified system is a refinement of the Gleason grading and valuable for contemporary clinical practice.

Growth Curves For Girls With Turner Syndrome.

The objective of this study was to review the growth curves for Turner syndrome, evaluate the methodological and statistical quality, and suggest potential growth curves for clinical practice guidelines. The search was carried out in the databases Medline and Embase. Of 1006 references identified, 15 were included. Studies constructed curves for weight, height, weight/height, body mass index, head circumference, height velocity, leg length, and sitting height. The sample ranged between 47 and 1,565 (total = 6,273) girls aged 0 to 24 y, born between 1950 and 2006. The number of measures ranged from 580 to 9,011 (total = 28,915). Most studies showed strengths such as sample size, exclusion of the use of growth hormone and androgen, and analysis of confounding variables. However, the growth curves were restricted to height, lack of information about selection bias, limited distributional properties, and smoothing aspects. In conclusion, we observe the need to construct an international growth reference for girls with Turner syndrome, in order to provide support for clinical practice guidelines.

Severity of Oral Mucositis in Patients Undergoing Hematopoietic Cell Transplantation and an Oral Laser Phototherapy Protocol: A Survey of 30 Patients

Background Data and Objective: Oral mucositis (OM) is one of the worst cytotoxic effects of chemotherapy and radiotherapy in patients undergoing hematopoietic cell transplantation (HCT), and it causes severe morbidity. Laser phototherapy has been considered as an alternative therapy for prevention and treatment of OM. The aim of this study was to describe the incidence and severity of OM in HCT patients subjected to laser phototherapy, and to discuss its effect on the oral mucosa. Patients and Methods: Information concerning patient age and gender, type of basic disease, conditioning regimen, type of transplant, absence or presence of pain related to the oral cavity, OM grade, and adverse reactions or unusual events were collected from 30 patients undergoing HCT (allogeneic or autologous). These patients were given oral laser phototherapy with a InGaAIP laser (660 nm and 40 mW) daily. The data were tabulated and their frequency expressed as percentages. Results: In the analysis of those with OM, it was observed that 33.4% exhibited grade I, 40% grade II, 23.3% grade III, and 3.3% grade IV disease. On the most critical post-HCT days (D+5 and D+8), it was observed that 63.3% of patients had grade I and 33.3% had grade II disease; no patients had grade III or IV disease in this period. This severity of OM was similar to that seen in other studies of laser phototherapy and OM. Conclusion: The low grades of OM observed in this survey show the beneficial effects of laser phototherapy, but randomized clinical trials are necessary to confirm these findings.

Pain threshold is achieved at intensity above anaerobic threshold in patients with intermittent claudication

PURPOSE: Walking training is considered as the first treatment option for patients with peripheral arterial disease and intermittent claudication (IC). Walking exercise has been prescribed for these patients by relative intensity of peak oxygen uptake (VO(2)peak), ranging from 40% to 70% VO(2)peak, or pain threshold (PT). However, the relationship between these methods and anaerobic threshold (AT), which is considered one of the best metabolic markers for establishing training intensity, has not been analyzed. Thus, the aim of this study was to compare, in IC patients, the physiological responses at exercise intensities usually prescribed for training (% VO(2) peak or % PT) with the ones observed at AT. METHODS: Thirty-three IC patients performed maximal graded cardiopulmonary treadmill test to assess exercise tolerance. During the test, heart rate (HR), VO(2), and systolic blood pressure were measured and responses were analyzed at the following: 40% of VO(2)peak; 70% of VO(2)peak; AT; and PT. RESULTS: Heart rate and VO(2) at 40% and 70% of VO(2)peak were lower than those at AT (HR: -13 +/- 9% and -3 +/- 8%, P < .01, respectively; VO(2): -52 +/- 12% and -13 +/- 15%, P < .01, respectively). Conversely, HR and VO(2) at PT were slightly higher than those at AT (HR: +3 +/- 8%, P < .01; VO(2): + 6 +/- 15%, P = .04). None of the patients achieved the respiratory compensation point. CONCLUSION: Prescribing exercise for IC patients between 40% and 70% of VO(2)peak will induce a lower stimulus than that at AT, whereas prescribing exercise at PT will result in a stimulus above AT. Thus, prescribing exercise training for IC patients on the basis of PT will probably produce a greater metabolic stimulus, promoting better cardiovascular benefits.

Surgical management of lung cancer in Western Australia in 1996 and its outcomes

Background: All cases of lung cancer diagnosed in Western Australia in 1996 in which surgery was the primary treatment, were reviewed. Reported herein are the characteristics of the patients, the treatment outcomes and a comparison of the management undertaken with that recommended by international guidelines. Methods: All patients with a new diagnosis of lung cancer in Western Australia in the calendar year of 1996 were identified using two different population-based registration systems: the Western Australian (WA) Cancer Registry and the WA Hospital Morbidity Data System. A structured questionnaire on the diagnosis and management was completed for each case. Date of death was determined through the WA Cancer Registry. Results: Six hundred and sixty-eight patients with lung cancer were identified; 132 (20%) were treated with surgery. Lobectomy was the most frequently performed procedure (71%), followed by pneumonectomy (19%). Major complications affected 23% of patients. Postoperative mortality was 6% (3% lobectomy, 12% pneumonectomy). At 5 years the absolute survival was as follows for stage I, II, IIIA, IIIB, respectively: 51%, 45%, 12%, 5%. Conclusions: Investigations and choice of surgery in WA in 1996 reflect current international guidelines. The survival of patients with resectable lung cancer remains unsatisfactory.

Surviving sepsis campaign in Brazil

Severe sepsis and septic shock have long been a challenge in intensive care because of their common occurrence, high associated costs of care, and significant mortality. The Surviving Sepsis Campaign (SSC) was developed in an attempt to address clinical inertia in the adoption of evidence-based strategies. The campaign relies on worldwide support from professional societies and has gained consensus on the management of patients with severe sepsis. The guidelines have subsequently been deployed into two bundles, with each bundle component sharing a common relationship in time. The widespread adoption of such evidence-based practice in clinical care has been disappointingly slow despite the quantifiable benefits regarding mortality. In Brazil, a country of continental dimensions with a heterogeneous population and unequal access to health services, this reality is no different. From 2004 to 2007, four prospective studies were published describing the country`s reality. In the multicenter Promoting Global Research Excellence in Severe Sepsis (PROGRESS) Study, the in-hospital mortality rate was higher in Brazil when compared with other countries: 56% against 30% in developed countries and 45% in other developing countries. During these 2.5 years of the campaign in Brazil, 43 hospitals have been receiving the necessary training to put in practice the recommended measures in all Brazilian regions, except for the North. The idea of the campaign is based on a 25% reduction in the relative risk of death from severe sepsis and septic shock within 5 years in the SSC-participating Brazilian hospitals. Ideally, the mortality rate should come to a 41.2% level subject to the 2009 deadline. This article aims to describe the actual scenario of the SSC implementation in Brazilian institutions and to report on some initiatives that have been used to overcome barriers.

Guideline-discordant care in acute myocardial infarction: predictors and outcomes

Objectives: To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care. Design: Retrospective cohort study. Setting: Two community general hospitals. Participants: 607 consecutive patients admitted with AMI between July 1997 and December 2000. Main outcome measures: Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay. Results: At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% Cl, 1.7-3.6), silent infarction (OR, 2.7; 95% Cl, 1.6-4.6), anterior infarction (OR, 2.5; 95% Cl, 1.7-3.8), a history of heart failure (OR, 6.3; 95% Cl, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% Cl, 1.5-6.4); and heart rate greater than or equal to 100 beats/min (OR, 2.1; 95% Cl, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% Cl, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% Cl, 0.90-7.1). Conclusions: Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI Such care appears to increase the risk of inhospital death.

Whither our Art? Clinical Wisdom & Evidence-based Medicine

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise.

Board composition and corporate performance: How the Australian experience informs contrasting theories of corporate governance

In many respects, Australian boards more closely approach normative best practice guidelines for corporate governance than boards in other Western countries. Do Australian firms then demonstrate a board demographic-organisational performance link that has not been found in other economies? We examine the relationships between board demographics and corporate performance in 348 of Australia's largest publicly listed companies and describe the attributes of these firms and their boards. We find that, after controlling for firm size, board size is positively correlated with firm value. We also find a positive relationship between the proportion of inside directors and the market-based measure of firm performance. We discuss the implications of these findings and compare our findings to prevailing research in the US and the UK.

An assessment of the integration of the mental health component into the care of women affected by intimate partner violence in Peru

RESUMO: A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica. legislação com base no género, saúde, guias, prevenção e mujeres 6 RESUMO (PORTUGUESE) A violência contra as mulheres (VCM) é um problema de saúde pública e uma violação dos direitos humanos. Ele tem uma alta prevalência na América Latina e no Caribe; o Estudo da Violência Contra as Mulheres da Organização Mundial de Saúde (OMS) identificou que as mulheres peruanas sofrem o maior índice de violência. O Perú é signatário da CEDAW e da Convenção de Belém do Pará, com recomendações para resolver este tipo de discriminação e descrever o papel do setor da saúde. A lei peruana define a violência como um problema de saúde mental. Objectivos: As três orientações clínicas do Ministério da Saúde para avaliar a integração da componente de saúde mental no cuidado de mulheres afetadas pela VCM foram revistas. Método: A proteção da saúde mental foi avaliada nas orientações acima mencionadas. A lei peruana relevante para perceber o reconhecimento das consequências de VCM na saúde mental e os cuidados prestados neste contexto foram revistos. Usando esses padrões nacionais e internacionais, foi realizada uma análise de conteúdo dos guias peruanos para a atenção da violência para ver como eles se integram a saúde mental. Resultados: Estas orientações são muito extensas e não definem claramente a responsabilidade dos profissionais de saúde. Não incluem um exame de saúde mental na avaliação da vítima e são vagas na descrição das atividades a serem realizadas pelo prestador dos cuidados de saúde. As orientações recomendam uma triagem universal usando um instrumento com formato antiquado e pesado. Em contrapartida, as orientações da OMS não recomendam qualquer triagem. Conclusão: As várias orientações analisadas não fornecem a informação necessária para o profissional de saúde avaliar o envolvimento da saúde mental e, desnecessariamente, tratam as mulheres sobreviventes de VCM como doentes mentais. Recomenda-se que as orientações recentes da OMS (Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, 2013) para os cuidados de VCM sejam usadas como um modelo para o desenvolvimento de um único dispositivo técnico que incorpora directrizes com base científica.-----------------ABSTRACT: Violence against women (VAW) is a public health problem and a human rights violation. It is highly prevalent in Latin America and the Caribbean; the Multi-country Study on Violence against Women by the World Health Organization identified rural Peruvian women as suffering the highest rates of VAW. The country is party to CEDAW and Belen Do Para Conventions, which set forth recommendations to overcome this form of discrimination and describe the role of the health sector. Peruvian law defines violence as a mental health issue. Objective: The Ministry of Health’s three technical guidelines were reviewed to assess the integration of mental health into the care of women affected by violence Method: The protection of the woman’s mental health was ascertained in the conventions mentioned above. The recognition of the mental health consequences of VAW and the inclusion of its evaluation and care were assessed in pertinent Peruvian legislation. Using these international and national parameters, the three guidelines for the attention of violence were subject to content analysis to see whether they conform to the conventions and integrate mental health care. Outcome: These guidelines are too extensive and do not clearly define the responsibility of health workers. They do not include a mental health exam in the evaluation of the victim and are vague in the description of the actions to be carried out by the health care provider. Guidelines prescribe universal screening using an outdated instrument and moreover, WHO Guidelines do not recommend screening. Conclusion: These multiple guidelines do not provide useful guidance for health care providers, particularly for the assessment of mental health sequelae, and unnecessarily stigmatize survivors of violence as mentally ill. It is recommended that the World Health Organization’s document Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines (2013) be used as a blueprint for only one technical instrument that incorporates evidence -based national policy and guidelines.

Violence: les femmes font confiance au milieu médical [Partner violence: women trust health professionals]

In 2008, the department of gynaecology and obstetrics of a university hospital centre implemented a program addressing interpersonal partner violence (screening, prevention and care of the patient victims). A qualitative survey was conducted to identify the needs and feelings of patients. The results show that patients are in favour of being actively and directly questioned about violence during the consultation and that they trust medical doctors and nurses to help and support them.

Evaluation de la douleur chez les personnes cérébrolésées non-communicantes aux soins intensifs

La douleur est fréquente en milieu de soins intensifs et sa gestion est l'une des missions des infirmières. Son évaluation est une prémisse indispensable à son soulagement. Cependant lorsque le patient est incapable de signaler sa douleur, les infirmières doivent se baser sur des signes externes pour l'évaluer. Les guides de bonne pratique recommandent chez les personnes non communicantes l'usage d'un instrument validé pour la population donnée et basé sur l'observation des comportements. A l'heure actuelle, les instruments d'évaluation de la douleur disponibles ne sont que partiellement adaptés aux personnes cérébrolésées dans la mesure où ces personnes présentent des comportements qui leur sont spécifiques. C'est pourquoi, cette étude vise à identifier, décrire et valider des indicateurs, et des descripteurs, de la douleur chez les personnes cérébrolésées. Un devis d'étude mixte multiphase avec une dominante quantitative a été choisi pour cette étude. Une première phase consistait à identifier des indicateurs et des descripteurs de la douleur chez les personnes cérébrolésées non communicantes aux soins intensifs en combinant trois sources de données : une revue intégrative des écrits, une démarche consultative utilisant la technique du groupe nominal auprès de 18 cliniciens expérimentés (6 médecins et 12 infirmières) et les résultats d'une étude pilote observationnelle réalisée auprès de 10 traumatisés crâniens. Les résultats ont permis d'identifier 6 indicateurs et 47 descripteurs comportementaux, vocaux et physiologiques susceptibles d'être inclus dans un instrument d'évaluation de la douleur destiné aux personnes cérébrolésées non- communicantes aux soins intensifs. Une deuxième phase séquentielle vérifiait les propriétés psychométriques des indicateurs et des descripteurs préalablement identifiés. La validation de contenu a été testée auprès de 10 experts cliniques et 4 experts scientifiques à l'aide d'un questionnaire structuré qui cherchait à évaluer la pertinence et la clarté/compréhensibilité de chaque descripteur. Cette démarche a permis de sélectionner 33 des 47 descripteurs et valider 6 indicateurs. Dans un deuxième temps, les propriétés psychométriques de ces indicateurs et descripteurs ont été étudiés au repos, lors de stimulation non nociceptive et lors d'une stimulation nociceptive (la latéralisation du patient) auprès de 116 personnes cérébrolésées aux soins intensifs hospitalisées dans deux centres hospitaliers universitaires. Les résultats montrent d'importantes variations dans les descripteurs observés lors de stimulation nociceptive probablement dues à l'hétérogénéité des patients au niveau de leur état de conscience. Dix descripteurs ont été éliminés, car leur fréquence lors de la stimulation nociceptive était inférieure à 5% ou leur fiabilité insuffisante. Les descripteurs physiologiques ont tous été supprimés en raison de leur faible variabilité et d'une fiabilité inter juge problématique. Les résultats montrent que la validité concomitante, c'est-à-dire la corrélation entre l'auto- évaluation du patient et les mesures réalisées avec les descripteurs, est satisfaisante lors de stimulation nociceptive {rs=0,527, p=0,003, n=30). Par contre la validité convergente, qui vérifiait l'association entre l'évaluation de la douleur par l'infirmière en charge du patient et les mesures réalisés avec les descripteurs, ainsi que la validité divergente, qui vérifiait si les indicateurs discriminent entre la stimulation nociceptive et le repos, mettent en évidence des résultats variables en fonction de l'état de conscience des patients. Ces résultats soulignent la nécessité d'étudier les descripteurs de la douleur chez des patients cérébrolésés en fonction du niveau de conscience et de considérer l'hétérogénéité de cette population dans la conception d'un instrument d'évaluation de la douleur pour les personnes cérébrolésées non communicantes aux soins intensifs. - Pain is frequent in the intensive care unit (ICU) and its management is a major issue for nurses. The assessment of pain is a prerequisite for appropriate pain management. However, pain assessment is difficult when patients are unable to communicate about their experience and nurses have to base their evaluation on external signs. Clinical practice guidelines highlight the need to use behavioral scales that have been validated for nonverbal patients. Current behavioral pain tools for ICU patients unable to communicate may not be appropriate for nonverbal brain-injured ICU patients, as they demonstrate specific responses to pain. This study aimed to identify, describe and validate pain indicators and descriptors in brain-injured ICU patients. A mixed multiphase method design with a quantitative dominant was chosen for this study. The first phase aimed to identify indicators and descriptors of pain for nonverbal brain- injured ICU patients using data from three sources: an integrative literature review, a consultation using the nominal group technique with 18 experienced clinicians (12 nurses and 6 physicians) and the results of an observational pilot study with 10 traumatic brain injured patients. The results of this first phase identified 6 indicators and 47 behavioral, vocal and physiological descriptors of pain that could be included in a pain assessment tool for this population. The sequential phase two tested the psychometric properties of the list of previously identified indicators and descriptors. Content validity was tested with 10 clinical and 4 scientific experts for pertinence and comprehensibility using a structured questionnaire. This process resulted in 33 descriptors to be selected out of 47 previously identified, and six validated indicators. Then, the psychometric properties of the descriptors and indicators were tested at rest, during non nociceptive stimulation and nociceptive stimulation (turning) in a sample of 116 brain-injured ICLI patients who were hospitalized in two university centers. Results showed important variations in the descriptors observed during the nociceptive stimulation, probably due to the heterogeneity of patients' level of consciousness. Ten descriptors were excluded, as they were observed less than 5% of the time or their reliability was insufficient. All physiologic descriptors were deleted as they showed little variability and inter observer reliability was lacking. Concomitant validity, testing the association between patients' self report of pain and measures performed using the descriptors, was acceptable during nociceptive stimulation (rs=0,527, p=0,003, n=30). However, convergent validity ( testing for an association between the nurses' pain assessment and measures done with descriptors) and divergent validity (testing for the ability of the indicators to discriminate between rest and a nociceptive stimulation) varied according to the level of consciousness These results highlight the need to study pain descriptors in brain-injured patients with different level of consciousness and to take into account the heterogeneity of this population forthe conception of a pain assessment tool for nonverbal brain-injured ICU patients.

Comparing impact and cost-effectiveness of primary prevention strategies for lipid-lowering.

BACKGROUND: Lipid-lowering therapy is costly but effective at reducing coronary heart disease (CHD) risk. OBJECTIVE: To assess the cost-effectiveness and public health impact of Adult Treatment Panel III (ATP III) guidelines and compare with a range of risk- and age-based alternative strategies. DESIGN: The CHD Policy Model, a Markov-type cost-effectiveness model. DATA SOURCES: National surveys (1999 to 2004), vital statistics (2000), the Framingham Heart Study (1948 to 2000), other published data, and a direct survey of statin costs (2008). TARGET POPULATION: U.S. population age 35 to 85 years. Time Horizon: 2010 to 2040. PERSPECTIVE: Health care system. INTERVENTION: Lowering of low-density lipoprotein cholesterol with HMG-CoA reductase inhibitors (statins). OUTCOME MEASURE: Incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Full adherence to ATP III primary prevention guidelines would require starting (9.7 million) or intensifying (1.4 million) statin therapy for 11.1 million adults and would prevent 20,000 myocardial infarctions and 10,000 CHD deaths per year at an annual net cost of $3.6 billion ($42,000/QALY) if low-intensity statins cost $2.11 per pill. The ATP III guidelines would be preferred over alternative strategies if society is willing to pay $50,000/QALY and statins cost $1.54 to $2.21 per pill. At higher statin costs, ATP III is not cost-effective; at lower costs, more liberal statin-prescribing strategies would be preferred; and at costs less than $0.10 per pill, treating all persons with low-density lipoprotein cholesterol levels greater than 3.4 mmol/L (>130 mg/dL) would yield net cost savings. RESULTS OF SENSITIVITY ANALYSIS: Results are sensitive to the assumptions that LDL cholesterol becomes less important as a risk factor with increasing age and that little disutility results from taking a pill every day. LIMITATION: Randomized trial evidence for statin effectiveness is not available for all subgroups. CONCLUSION: The ATP III guidelines are relatively cost-effective and would have a large public health impact if implemented fully in the United States. Alternate strategies may be preferred, however, depending on the cost of statins and how much society is willing to pay for better health outcomes. FUNDING: Flight Attendants' Medical Research Institute and the Swanson Family Fund. The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute.