Making health systems more equitable

Health systems are consistently inequitable, providing more and higher quality services to the well-off, who need them less, than to the poor, who are unable to obtain them. In the absence of a concerted effort to ensure that health systems reach disadvantaged groups more effectively, such inequities are likely to continue. Yet this situation need not be accepted as inevitable, for there are many promising measures that might be pursued: establishment of goals for improved coverage in the poor, rather than in entire populations, and use of those goals to direct planning toward the needs of the disadvantaged; use of one or more of the several techniques that seem to have been effective in at least some of the settings where they have been tried; and empowerment of poor clients to have a more central role in health system design and operation.     

Epidemiology, clinical characteristics, outcome, morbidity and mortality in acromegaly based on the Spanish Acromegaly Registry (Registro Espanol de Acromegalia, REA)

OBJECTIVE: To undertake a multicentre epidemiological study reflecting acromegaly in Spain. DESIGN: Voluntary reporting of data on patients with acromegaly to an online database, by the managing physician. METHODS: Data on demographics, diagnosis, estimated date of initial symptoms and diagnosis, pituitary imaging, visual fields, GH and IGF-I concentrations (requested locally), medical, radiotherapy and neurosurgical treatments, morbidity and mortality were collected. RESULTS: Data were included for 1219 patients (60.8% women) with a mean age at diagnosis of 45 years (s.d. 14 years). Reporting was maximal in 1997 (2.1 cases per million inhabitants (c.p.m.) per year); prevalence was globally 36 c.p.m., but varied between 15.7 and 75.8 c.p.m. in different regions. Of 1196 pituitary tumours, most were macroadenomas (73%); 81% of these patients underwent surgery, 45% received radiotherapy and 65% were given medical treatment (somatostatin analogues in 68.3% and dopamine agonists in 31.4%). Cures (GH values (basal or after an oral glucose tolerance test) <2 ng/ml, normal IGF-I, or both) were observed in 40.3% after surgery and 28.2% after radiotherapy. Hypertension (39.1%), diabetes mellitus (37.6%), hypopituitarism (25.7%), goitre (22.4%), carpal tunnel syndrome (18.7%) and sleep apnoea (13.2%) were reported as most frequent morbidities; 6.8% of the patients had cancer (breast in 3.1% of the women and colon in 1.2% of the cohort). Fifty-six patients died at a mean age of 60 years (s.d. 14 years), most commonly of a cardiovascular cause (39.4%); mortality was greater in patients given radiotherapy (hazard ratio 2.29; 95% confidence interval 1.03 to 5.08; P=0.026), and in those in whom GH and IGF-I concentrations were never normal (P<0.001). CONCLUSIONS: This acromegaly registry offers a realistic overview of the epidemiological characteristics, treatment outcome and morbidity of acromegaly in Spain. As active disease and treatment with radiotherapy are associated with an increase in mortality, efforts to control the disease early are desirable.     

Long-term effects of a nationwide control program on the seropositivity for Trypanosoma cruzi infection in young men from Argentina

Unselected nationwide cohorts of Argentine men 18 years of age summoned for military service were tested for antibodies to Trypanosoma cruzi each year from 1981 to 1993. After an initial screening using indirect hemagglutination test, the positive sera were retested by titrated indirect hemagglutination and immunofluorescence antibody tests at 39 laboratories or at the national reference center in Buenos Aires. Nearly 1.8 million men were examined for T. cruzi antibodies using the same standardized procedures under a quality assurance program. The prevalence of seropositivity for T. cruzi decreased significantly from 5.8% in 1981 to 1.9% in 1993, but the decrease was not homogeneous among provinces within each region or constant over time. Prior to the nationwide control campaign initiated in 1961-1962, 15 provinces had high (> 20%) percentages of houses with domiciliary infestation by Triatoma infestans bugs, which decreased to nine provinces in 1982, and four provinces in 1992. The observed decrease in the prevalence of seropositivity for T. cruzi may be mostly attributed to the spraying with insecticides to eliminate the domiciliary populations of Triatoma infestans. The lack of a sustainable triatomine surveillance program set a limit to the decrease of seropositivity rates and prompted a revised strategy based on community participation.     

Current status of the rheumatologists’ workforce in Latin America: a PANLAR collaborative study

Clinical Rheumatology - Studies conducted by various scientific societies have shown that the demand for specialized rheumatology care is greater than the projected growth of the workforce. Our...     

The cerebrospinal fluid/serum leptin ratio during pharmacological therapy for obesity

The aim of the present study was to evaluate the cerebrospinal fluid (CSF)/serum leptin ratio during pharmacological therapy for obesity with centrally and peripherally acting drugs. Thirty-one obese women (mean age, 32.3 +/- 10 yr; body mass index, 38.2 +/- 5.2 kg/m(2); body fat, 43.3 +/- 5.4%) were studied before and 2 months after a weight loss program consisting of a balanced diet (1200 kcal/d) plus drug therapy. The patients were randomly assigned into three study groups: group I, fenproporex 25 mg/d (n = 10); group II, sibutramine 10 mg/d (n = 10); and group III, orlistat 120 mg tid (n = 11). Body fat, measured by dual-energy x-ray absorptiometry, and serum and CSF concentrations of leptin were examined at baseline and 2 months after therapy. At baseline, clinical and biochemical characteristics of the groups were similar. All of the women lost weight, approximately 7.0% of their initial body weight, and the reduction was not different among the groups. Serum leptin fell significantly after 2 months in all groups, and the decline was proportional to the reduction in body fat, because leptin levels adjusted for body fat did not change after treatment. CSF leptin levels showed a significant decrease after 2 months in all groups, and this decline was higher on group III compared with group I (P = 0.006). After therapy, the CSF/serum leptin ratio did not change in group I (1.57 +/- 0.3 to 1.72 +/- 0.62%) and group II (1.78 +/- 1.01 to 1.69 +/- 1.27%), whereas it declined significantly in group III (1.65 +/- 0.43 to 1.09 +/- 0.47%; P < 0.01), corresponding to a decrease of 33.3 +/- 22.5% for the CSF/serum leptin ratio. The percentage change in group III was significantly different from the positive variation on group I (11.9 +/- 42.1%; P = 0.006) and close to the statistical significance compared with the negative variation seen in group II (-7.6 +/- 27.8%; P = 0.06). Our results showed that the CSF/serum leptin ratio decreased after weight loss in obese women treated during 2 months with orlistat, whereas this ratio did not change in this period of time in obese women treated with fenproporex and sibutramine.     

Cardiovascular therapy in patients with renal insufficiency

Chronic renal failure and arterial hypertension run in parallel. New goal blood pressure levels have been established in 130/85 mmHg and 125/75 mmHg depending on the level of proteinuria being below or above 1 g/day.New and lower threshold BP (>130/85 mmHg) to initiate pharmacologic therapy are required in the presence of renal failure in order to facilitate the strict BP control that is required.Renal insufficiency is accompanied since its initial stages by a marked increase in cardiovascular risk and serum creatinine, its estimated clearance and the presence of proteinuria are very powerful predictors of a bad cardiovascular outcome. Hence, the need to consider that both renal and cardiovascular protection are obtained with such a strict BP control which, otherwise seems to require blockade of angiotensin II effects when proteinuria above 1g/day is present.Prevention of renal failure related to elevated blood pressure requires of strict blood pressure control, usually obtained with combination of two or more antihypertensive agents, one of them capable of blocking angiotensin II. Besides this, strict control of associated cardiovascular risk factors is also required.