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OBJECTIVES: The objective is to describe and analyze how outlier admission influences hospital stay and the appearance of complications in patients with a femoral neck fracture treated with arthroplasty. MATERIAL AND METHOD: A historical cohort study was carried out in which the group of patients with a displaced fracture of the femoral neck who had an outlier admission was defined as an exposed cohort, that is, they were admitted to a hospitalization area not belonging to the Orthopedic Surgery and Traumatology department, unlike the unexposed cohort, that included patients admitted to a hospitalization area assigned to the Orthopedic Surgery and Traumatology department. RESULTS: Outlier admission was a risk factor for requiring a postoperative transfusion (RR 1.52, 95% CI 1.05-2.21; P=.035), to have a postoperative stay longer than 5 days (RR 1.35, 95% CI 1.04-1.74; P=.038) and to suffer general postoperative complications (RR 1.35, 95% CI 1.02-1.78; P=.048). CONCLUSIONS: Outlier admission is a threat to the quality and safety of health care. In patients over 80 years of age, medical outliers is a risk factor for postoperative transfusion and systemic postoperative complications.

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OBJECTIVE: To review the scientific evidence with respect to the use of digital mammography and compare it with analogical mammography in the clinical context. MATERIAL AND METHOD: We searched Medline and EMbase for studies published between 1989 and 2005 that compared the results of digital and analogical mammography in the same group of patients or in two different groups of patients to evaluate their respective diagnostic accuracy (sensitivity, specificity, area under the ROC curve), recall rate, biopsy rate, and exposure to radiation. We reviewed and compared the different methodologies of the studies published. RESULTS: Eight articles and eight presentations at congresses were found. No statistically significant differences were observed between digital and analogical mammography for the detection of breast cancer. Until the publication of the Oslo II (2004) and Digital Mammographic Imaging Screening Trial (2005) studies, the series presented were small and used a variety of methodologies. This made it impossible to appreciate small differences in diagnostic accuracy between the two techniques and to group the, sometimes, contradictory results. Furthermore, these first series did not include follow-up. CONCLUSION: There are no statistically significant differences between the two techniques for diagnostic accuracy, except in women with dense or heterogeneously dense breasts, in those under 50 years of age, and in peri- or pre-menopausal women, in which cases digital mammography is significantly better. These data should be confirmed in longer term studies to enable the effects on the breast cancer mortality rate to be specifically evaluated. Cost-effectiveness studies are important when considering changing techniques.

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INTRODUCTION: After ten years of clinical use of Finasteride in patients with BPH, we carried out a systematic review of the literature including the assessment of their quality and grading the level of evidence for clinical recommendations. METHODS: Using Medline, Embase, Healthstar and Cochrane Library from 1990 until 2002, we select all the studies referring patients between 50 to 85 with symptoms of BPH, metrics of flow, prostatic volume, postmictional residue, detrusor pressure, adverse effects, cost-effectiveness and quality of life. RESULTS: We found out 135 references, of which 36 accomplish the inclusion criteria. Of those, 3 have got level I of evidence, 12 level II, 6 level III and 10 level IV. Three are economic studies and two evaluate the quality of life. DISCUSSION: With a high level of evidence and after ten years of clinical use, Finasteride shows its effectiveness in reducing the symptoms of patients with prostate bigger than 40 ml and/or PSA of more than 1.4 ngr/ml, with scarce adverse effects with a clear improvement of quality of life. Therefore, it is recommended (grade A) for clinical use. CONCLUSIONS: Finasteride, through prostate volume reduction, modify natural evolution of BPH, decreasing the risk of acute urine retention and surgery.

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The following paper analyses the relationship between cost-effective medicine and evidence-based medicine and their complementary aspects. Clear concepts and methods are pointed out. Useful examples of both approaches for daily clinical practice are given. Individual and social perspectives are presented including their impact on clinical decision making.

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The contribution of evidence based medicine (EBM) methodology to the clinical practice of symptomatic benign prostatic hyperplasia (BPH) patients may be very helpful. Otherwise its development is incipient. BPH is still a high prevalent and far-reaching clinicopathologic entity. In the last few years, new drug and surgical therapies have emerged that have significantly changed BPH clinical management. In this article, the elements that make feasible the application of EBM to the clinical management of BPH patients are reviewed, with the aim of making this relation part of the vast extension of EBM in the different medical specialties. This objective is an answer to the double interest, on one hand, in defining the importance of this new concept of medical practice and, on the other hand, in making clinical practice suitable for solving the queries of a disease with such a variable influence in patient's welfare and quality of life. We therefore conclude that application of EBM methodology to BPH management is relevant and necessary.

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Evidence-based medicine originates in 1992 when the proliferation of medical publications and other clinically relevant information was neither organized nor efficiently employed, aggravating concerns on the ethical duty of its incorporation to clinical decision making. Development of clinical research and its methods have changed the nature of medical knowledge, "changing the paradigm" leading to need for changing both practice organization and the contents of continuous education. This is the "objective basis" of evidence-based medicine. Since evidence-based medicine emphasizes the clinician's judgement and asses the knowledge basis of his practice, reinforces professional autonomy compared to other considerations, thus having political and ethical implications. Evidence-based medicine redefines in its own terms professional excellence.

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Health care evidence based is a 90's trend of health professionals interested in the scientific development of effectiveness and efficiency research into the health management and introducing scientific evidence into the health decision-making process. The development of health services research, outcome management and evidence based medicine, makes possible the new orientation of heath systems toward health care evidence based. That means health services provided with the maximum quality, effectiveness, appropriateness and taking into account the informed patients preferences. If we want to see health care evidence based fully working among managers and clinicians, we need the development of information systems directed to the measurement of clinical outcomes in terms of effectiveness and efficiency, as well as specific plus tailored training programs and, pushing focused research areas into the improvement of health services provided at hospital and primary care levels.

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OBJECTIVES: The general objective of this investigation is to know the possible consequences of long-term unemployment on the family and social environment, as well as the mechanisms which lead to the appearance of health problems among long-term unemployed people. METHODS: The subjects of this study were long-term unemployed people of 35 to 55 years of age of the municipal term of Madrid, with families depending on them. This is a qualitative-intensive investigation, with special emphasis on the individual, social, sanitary and economical aspects. The instrument of common measurement was the combination of the discussion group integrated by five people, during approximately 120 minutes, with focused and individual interviews (48) over a semistructured script, during approximately 60 minutes, using recording instruments (audio tape). RESULTS: During the development of the discussion group a worsening of the psychological health and family situation was observed as a consequence of remaining unemployed. In the more thorough interviews we could detect clear differences according to the impact of unemployment on health depending on the low socioeconomical area, women and older unemployed people. CONCLUSIONS: The effects of unemployment on health cannot be isolated from other underlying bad social and economical conditions, that is to say, from social, economical, educative inequalities, etc., previous to the unemployment situation.

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