Necesidad de variaciones en las estructuras hospitalarias de los servicios de geriatría / Need for variations in the hospital structures of the geriatrics services

El envejecimiento conlleva a variaciones en las estructuras hospitalarias. La experiencia del autor durante más de 20 años en la atención hospitalaria a adultos mayores reservistas y veteranos de la defensa, permite afirmar que debemos continuar trabajando por mejorar las capacidades estructurales y la asistencia geriátrica. Una investigación realizada en adultos mayores veteranos de la defensa mostró la existencia de elevada prevalencia de diversas deficiencias y enfermedades crónicas que afectan la salud. Los Hospitales Militares Centrales y de Ejércitos deben de disponer de un Servicio de Geriatría donde los adultos mayores serán evaluados integralmente. Preparar las instituciones de salud para enfrentar el reto que impone el envejecimiento poblacional constituye una proyección estratégica de trabajo concebida en los Lineamientos del Partido(AU)

Aging leads to variations in hospital structures. The author's experience for more than 20 years in hospital care for elderly reservists and veterans allows us to affirm that we must continue working to improve structural capacities and geriatric care. An investigation in elderly veterans of the defense showed the existence of high prevalence of diverse deficiencies and chronic diseases that affect health. Central Military Hospitals and Army Hospitals must have a Geriatrics Service where the elderly will be fully evaluated. Preparing health institutions to meet the challenge of aging population is a strategic projection of work conceived in the Cuban Communist Party Guidelines(AU)

Early postoperative complications after coronary artery bypass grafting at the San Juan Veterans Affairs Medical Center

OBJECTIVES: Describe the perioperative characteristics of the patients undergoing coronary artery bypass grafting (CABG) in San Juan, Veterans Affairs Medical Center (SJ-VAMC). Determine the in-hospital and 30-day morbidity and mortality following CABG and identify adverse predictors for postoperative complications. BACKGROUND: Preoperative risk factors for complications post-CABG have been identified; however limited data is available regarding the value of these predictors in the Puerto Rican Population. METHODS: Perioperative characteristics and 30-day complications were gathered from all patients undergoing CABG (n = 252) at the SJ-VAMC (2001-2003). Logistic regression analysis was performed to determine factors associated with the occurrence of complications. RESULTS: The population's mean age was 66.9 +/- 8.1 years. Associated illnesses included: hypertension (95.6), diabetes (57), past smoking (61), COPD (26), chronic renal insufficiency (CRI-11.5), cerebrovascular disease (CVD-20.6), disabling angina (78), 3-vessel coronary disease (75.8), significant left main stenosis (20), and non-elective surgical intervention (54). The most frequent primary complications were postoperative myocardial infarction (MI-4.8) and congestive heart failure (4.8). The 30-day mortality was 1.2. Upon multivariate analysis PRBC transfusions > 3 units was associated to increased risks of primary complications, in patients with prior history of CVD. CRI and LVEF < or = 40were independently associated to development of primary complications, in patients with prior MI and CVD. CONCLUSION: The preoperative characteristics are suggestive of an older and sicker patient that is undergoing CABG at the SJ-VAMC. Despite this, the death rate was low and the frequency of other complications comparable to the Society of Thoracic Surgeons (STS) National Adult Cardiac Database.

Phenotypic confirmation of extended-spectrum B-lactamases (ESBL) in clinical isolates of Escherichia coli and Klebsiella pneumoniae at the San Juan Veterans Affairs Medical Center

Extended-spectrum Beta (beta)-lactamases (ESBLs) have emerged as an important mechanism of resistance to B-lactam antibiotics in gram-negative bacteria (GNB). They are enzymes that hydrolyze older B-lactam antibiotics as well as broad-spectrum cephalosporins and monobactams. ESBL producers have been reported in many bacteria but special attention has been paid to the ones in E.coli and Klebsiella spp. Detection of the ESBLs by the clinical laboratory is a special challenge. Surveillance to monitor resistance is important to decide when detection of ESBLs must be started. This study determined the prevalence of ESBL producers in the strains E.coli and K.pneumoniae at the San Juan VA Medical Center, and characterized their phenotypes to evaluate the importance to identify these bacteria as a standard routine procedure in the institution. All E.coli and K.pneumoniae isolated from Jan 1 to Mar 31, 2003 were evaluated according to National Committee for Clinical Laboratory Standards (NCCLS) screening criteria for suspected ESBL producers. Phenotypic confirmation of the ESBL production was performed using the Etest method. A total of 112/253 (44%) E.coli and 72/137 (53%) K.pneumoniae were identified as suspected ESBL producers. Etest was performed in 60% of the E.coli and 57% of the K.pneumoniae suspected to be ESBL producers. The overall ESBL prevalence for E.coli was 25% and in K.pneumoniae was 26%. Most E.coli ESBL-producers were from urine while the K.pneumoniae were from sputum. ESBL-producers were isolated from different sources including pleural and synovial fluids, blood, and skin besides urine and sputum. According to susceptibility results, the most reliable antibiotic in predicting a negative ESBL was cefpodoxime (CPD), and in the strains studied, the ESBL producers were consistently resistant to aztreonam (ATM). A large proportion (95%) of ESBL producing K.pneumoniae were susceptible to cefepime (CEP). Of the ESBL producing E.coli, 24% were susceptible. In the case of E.coli ESBLproducers, Cefepime can be considered as a therapeutic option if susceptibilities are available. Automated identification and sensitivity systems are valid alternatives for routine evaluation of B-lactam resistance but when increased resistance is documented in GNB and/or ESBL prevalence is high, ESBL detection should be performed. All confirmed ESBL producers should be reported resistant to all penicillins, cephalosporins, and aztreonam in spite of having susceptible ra

How do elderly veterans who fail to keep outpatient clinic appointments differ from those who do not

Este estudio cuestionó el por qué los veteranos de mayor edad no cumplián con sus citas en las clínicas ambulatorias de Medicina General y Cirugía en el Hospital de Veteranos de San Juan, Puerto Rico. Tres hipótesis fueron formuladas: 1. Los pacientes de mayor edad que no asisten a las citas tienen otras alternativas de cuidado médico en la comunidad. 2. Los pacientes de mayor edad que no asisten a las citas tienen un período mayor de espera entre las mismas. 3. Los pacientes de mayor edad con citas en diferents clínicas dentro de un período corto de tiempo no aisten a las mismas. El estudio eincluyó una muestra de cincuenta y tres pacientes de mayor edad, 30 que asistían a sus citas médicas y 23 que no asistían a las mismas. La entrevista estructurada consistia de preguntas de alternativas fijas y abiertas oara recoger los datos. Esta se diseñó para obtener datos sobre características socio demográficas, el uso de clínicas, problemas, relacionados con el uso de las clínicas ambulatorias y recomendaciones para mejorar los servicios. Se utilizó el análisis de porcentaje para señalar las diferencias y similaridades entre los grupos estudiados. Los hallazgos corroboraron la hipótesis de que los pacientes que no cumplían con sus citas, no solo utilizaron servicios médicos fueraa del hospital, sino que también poseían los recursos económicos para sufragar los mismos. Los datos también confirmaron que aquellos que no cumplieron con sus citas tenían que esperar un período más largo entre sus citas. Los pacientes que no cumprieron con sus citas las consideraron muy poco frecuentes, lo que resultó en que olvidan las mismas