Differences in partial oxygen saturation obtained from three pulse oximeters.

INTRODUCCIÓN: Se estima que existe variabilidad en la medición de la saturación parcial de oxígeno entre distintos oxímetros de pulso. OBJETIVO: Conocer la variabilidad de la medición de acuerdo con el oxímetro de pulso utilizado en la práctica clínica. MATERIAL Y MÉTODOS: Diseño transversal, sujetos consecutivos. Se obtuvieron variables demográficas, ocupación y enfermedad. Se estimaron las diferencias en la variabilidad de tres oxímetros de pulso. Las variables nominales se informaron con frecuencias y porcentajes; las numéricas, con promedios y desviación estándar. La variabilidad se calculó con el estadístico de Bland-Altman y su magnitud con el coeficiente de correlación intraclase (intervalo de confianza del 95%). RESULTADOS: Se estudiaron 255 pacientes con una edad promedio de 61 ± 15 años y un índice de masa corporal de 30.28 ± 6.59 kg/m2, de los cuales 145 (56.8%) fueron mujeres y 136 (53.33%) tuvieron hábito tabáquico. La ocupación y la enfermedad con mayor frecuencia fueron obrero (98; 38.43%) y enfermedad pulmonar obstructiva crónica (143; 56.08%). El promedio grupal de saturación arterial de oxígeno frente a saturación parcial de oxígeno fue de 91.28 ± 4.07% frente a 90.64 ± 3.89% (p < 0.0001). La diferencia media (límites de acuerdo) y el coeficiente de correlación intraclase (intervalo de confianza del 95%) fueron, respectivamente, para los tres oxímetros: Onyx II -0.5 (3.4, -4.3) y 0.949 (0.935, 0.960), Hergom 0.2 (3.4, -2.9) y 0.951 (0.937, 0.962), y Rossmax SB220 -1.6 (36.2, -39.5) y 0.784 (0.724, 0.831). CONCLUSIONES: Los oxímetros de pulso Onyx II y Hergom tuvieron menor variabilidad, mientras que el Rossmax SB220 la tuvo muy amplia, por lo que no resulta aconsejable para uso clínico. BACKGROUND: It may be estimated certain variability in the measurement of partial oxygen saturation between pulse oximeters. OBJECTIVE: Describe the variability of partial oxygen saturation obtained from three different pulse oximeters. MATERIAL AND METHODS: Cross design, consecutive subjects. Data related to demographic variables, occupation, diseases and differences in variability of three pulse oximeters was obtained. Nominal variables were reported with frequencies and percentages, numerical with averages and standard deviation; the variability was calculated with the Bland-Altman statistic and its magnitude with the intraclass correlation coefficient (95% confidence interval). RESULTS: The 255 patients studied were aged between 61 ± 15 years, body mass index ranked 30.28 ± 6.59 kg/m2, 145 (56.8%) were female and 136 (53.33%) had tobacco smoking habit. The most frequent occupation were worker (98; 38.43%), and disease chronic obstructive pulmonary disease (143; 56.08%). Group average of arterial oxygen saturation vs. partial oxygen saturation: 91.28 ± 4.07% vs. 90.64 ± 3.89% (p < 0.0001). For the three oxymeters, the mean difference (limits of agreement) and the intraclass correlation coefficient (95% confidence interval) were respectively: Onyx-II −0.5 (3.4, −4.3), 0.949 (0.935, 0.960), Hergom 0.2 (3.4, −2.9), 0.951 (0.937, 0.962) and Rossmax SB220 −1.6 (36.2, −39.5), 0.784 (0.724, 0.831). CONCLUSIONS: Onyx II and Hergom pulse oximeters had low variability, while SB220 showed ample variability and it is therefore, not advisable to use in clinical practice.

Pulmonary endarterectomy. Initial report in a cardiology hospital / Endarterectomía pulmonar. Reporte inicial en un hospital de cardiología

Background: Currently the options for treatment of chronic thromboembolic pulmonary hypertension can be pulmonary endarterectomy, pulmonary angioplasty and pharmacological treatment. Objective: To show the feasibility of performing pulmonary endarterectomy in a cardiology hospital. Methods: From December 2013 to June 2014 a serie of consecutive cases was studied according to the guidelines of the Fifth World Symposium of Pulmonary Hypertension. Its antecedents, clinical characteristics, functional class, hemodynamics, exercise capacity were defined in pre and post-operative conditions. Results: Three cases, two males with A + blood group and one female O + with presence of antiphospholipid antibodies; the three patients with prior history of pulmonary embolism, obese, with dyspnea and syncope; preoperative systolic pulmonary pressures were 60, 50, 59 mm Hg, and post-operative 43, 33, 21 mm Hg; functional class III/IV vs. I/IV; walked meters 320, 266, 252 vs. 480, 527, 0, respectively. One patient died, not related to surgery, due to multiple organ failure 40 days after surgery. Conclusions: Pulmonary endarterectomy is a feasible procedure with clinical and hemodynamic improvement.

Introducción: actualmente, las opciones de tratamiento de la hipertensión pulmonar tromboembólica crónica pueden ser la endarterectomía pulmonar, la angioplastía pulmonar y el tratamiento farmacológico. Objetivo: mostrar la factibilidad de realizar la endarterectomía pulmonar en un hospital de cardiología. Métodos: de diciembre del 2013 a junio del 2014 se estudió una serie de casos consecutivos de acuerdo con las guías del 5to Simposio Mundial sobre Hipertensión Pulmonar. Se indagaron sus antecedentes, características clínicas, clase funcional, hemodinámica y capacidad de ejercicio, en condiciones pre- y posoperatorias. Resultados: se operaron tres pacientes, dos varones con grupo sanguíneo A+ y una mujer O+ con presencia de anticuerpos antifosfolípidos; los tres pacientes tenían antecedentes de embolia pulmonar previa, obesos, con disnea y síncope; las presiones pulmonares sistólicas preoperatorias fueron de 60, 50, 59 mm Hg, respectivamente, y posoperatorias de 43, 33, 21 mm Hg; clase funcional III/IV frente a I/IV; metros caminados 320, 266, 252 frente a 480, 527 y cero, respectivamente. Un paciente falleció por falla orgánica múltiple a 40 días del posoperatorio, el desenlace no estuvo relacionado con la cirugía. Conclusiones: la endarterectomía pulmonar es un procedimiento factible de realizar con mejoría clínica y hemodinámica.

Variability of arterial and peripheral venous blood gases parameters in subjects with stable obstructive pulmonary disease / Variabilidad de los parámetros de la gasometría arterial y venosa periférica en sujetos con enfermedad pulmonar obstructiva crónica en condición estable

Background: Peripheral venous blood gases may be useful in subjects with exacerbation of chronic obstructive pulmonary disease to evaluate their gas exchange. Objective: To describe the variability of parameters of arterial and peripheral venous blood gases in subjects with stable obstructive pulmonary disease. Methods: Cross-sectional design, consecutive subjects were studied in a blinded manner, while arterial and peripheral venous blood was obtained for analysis. Variability was established with Bland-Altman statistical method and its magnitude with the intraclass correlation coefficient (95 % confidence interval). Results: Three hundred blood samples from 150 patients were studied, 89 (59.3%) women, age 66 ± 10 years old, body mass index 28.44 ± 4.81 Kg/m2. Mean difference (bias) [intraclass correlation coeficient] pH 0.012 (-0.009, 0.032) [0.927], Carbon dioxide pressure -6.5 (-14.1, 1.1) [ 0.643], serum bicarbonate -1.3 (-3.3, 0.7) [0.929], base excess -1 (-4, 2.1) [0.904], hemoglobin -0.1 (-1.9, 1.8) [0.947]. Conclusions: The variability of pH, serum bicarbonate, and hemoglobin are similar in both blood samples. These arterial or peripheral venous blood gas parameters could be used interchangeably.

Introducción: la gasometría venosa periférica puede ser de utilidad en sujetos con exacerbación de la enfermedad pulmonar obstructiva crónica para evaluar su intercambio gaseoso. Objetivo: describir la variabilidad de los parámetros de la gasometría arterial y venosa periférica en sujetos con enfermedad pulmonar obstructiva crónica en condición estable. Métodos: diseño transversal, se estudiaron sujetos consecutivos de forma cegada, al mismo tiempo se obtuvo sangre arterial y venosa periférica para su análisis. La variabilidad se determinó con el método estadístico de Bland-Altman y su magnitud con el coeficiente de correlación intraclase (intervalo de confianza al 95%). Resultados: se estudiaron 300 muestras sanguíneas de 150 pacientes, 89 mujeres (59.3%), edad del grupo 66 ± 10 años, el índice de masa corporal 28.44 ± 4.81 Kg/m2. La diferencia media (sesgo) [coeficiente de correlación intraclase] para el pH: 0.012 (-0.009, 0.032) [0.927], presión de bióxido de carbono: -6.5 (-14.1, 1.1) [ 0.643], bicarbonato sérico: -1.3 (-3.3, 0.7) [0.929], y exceso de base: -1 (-4, 2.1) [0.904], hemoglobina: -0.1 (-1.9, 1.8) [0.947]. Conclusiones: la variabilidad del pH, el bicarbonato sérico y la hemoglobina son similares en ambas muestras sanguíneas. Estos parámetros de la gasometría arterial o venosa periférica podrían ser utilizados en forma intercambiable.

Association between environmental factors and hospitalisations for bronchiectasis in Badalona, Barcelona, Spain (2007-2015). / Asociación entre factores ambientales e ingresos por bronquiectasias en Badalona, Barcelona (2007-2015).

INTRODUCTION: The relationship between environmental factors and the exacerbation of respiratory diseases has been widely studied. However, there are no studies examining the relationship between these factors and bronchiectasis exacerbations. Our objective was to analyse the association between various environmental factors and hospitalisation for bronchiectasis. MATERIAL AND METHODS: This was a retrospective observational study conducted at two hospitals in Badalona (Barcelona). The number of hospital admissions for exacerbation of bronchiectasis between 2007 and 2015 was obtained. Through multiple regression we analysed the relationship between the number of exacerbations and mean monthly values of temperature, SO2, NO, NO2, O3 and CO. RESULTS: Temperature, SO2, NO, NO2, O3 and CO were significantly associated with an increase in admissions due to exacerbation of bronchiectasis. By controlling the effect of temperature on the pollution variables, only SO2 maintained statistical significance (P=.008). CONCLUSION: We have detected an increase in hospital admissions for exacerbation of bronchiectasis with increases in the atmospheric concentration of SO2 and the decrease in temperature. Prospective studies with different geographical locations to confirm these results are needed.

Carbapenem-Resistant Enterobacteriaceae Detection Practices in California: What Are We Missing?

Background: The Clinical and Laboratory Standards Institute (CLSI) revised the carbapenem breakpoints for Enterobacteriaceae in 2010. The number of hospitals that adopted revised breakpoints and the clinical impact of delayed adoption has not been explored. Methods: We performed a cross-sectional, voluntary survey of microbiology laboratories from California acute care hospitals and long-term acute care hospitals (LTAC) to determine use of revised CLSI breakpoints. Carbapenem-resistant Enterobacteriaceae (CRE) clinical isolates from a single tertiary-care hospital from 2013 to 2017 were examined. All isolates with an elevated minimum inhibitory concentration (MIC; ≥2 µg/mL) to imipenem or meropenem were tested for the presence of carbapenemase genes by polymerase chain reaction (PCR). Results: We received responses from 128 laboratories that serve 264/393 (67%) of hospitals and LTACs. Current CLSI carbapenem breakpoints for Enterobacteriaceae were used by 92/128 (72%) laboratories. Among laboratories that used current breakpoints, time to implementation varied from 0 to 68 months (mean, 41 months; median, 55 months). Application of historical breakpoints to isolates with a carbapenemase gene detected by PCR resulted in susceptibility rates of 8.9%, 18.6%, and 18.6% to ertapenem, imipenem, and meropenem, respectively. By current breakpoints, <1% of these isolates were susceptible to ertapenem or imipenem and 2.6% to meropenem. Conclusion: Clinicians and epidemiologists should be aware that use of outdated MIC breakpoints for Enterobacteriaceae remains common and can result in reports of false susceptibility to carbapenems and missed identification of carbapenemase producers. This misclassification could have consequences for patient care and infection control efforts to address carbapenemase-producing Enterobacteriaceae.

[The pulmonary hypertension of the chronic kidney disease]. / La hipertensión pulmonar de la enfermedad renal crónica.

Pulmonary hypertension in chronic kidney disease is included in the group 5 of the pulmonary hypertension classification of the World Health Organization. Its mechanism is multifactorial and little known. Its importance has increased due to its impact on survival according to whether they received a kidney transplant, the greater risk of early renal graft loss and major hospital stays. In this review, we analyze the panorama of chronic renal disease in Mexico and Latin America, the epidemiology, pathophysiological mechanisms, the diagnostic process and the treatment of pulmonary hypertension in chronic kidney disease.

La hipertensión pulmonar de la enfermedad renal crónica está contemplada en el grupo 5 de la clasificación de hipertensión pulmonar de la Organización Mundial de la Salud. Su mecanismo es multifactorial y poco conocido. Su importancia ha incrementado debido a su impacto en la supervivencia de acuerdo a si el paciente recibió un trasplante renal, al mayor riesgo de pérdida temprana del injerto renal y a las estancias hospitalarias mayores. En esta revisión, se analiza el panorama de la enfermedad renal crónica en México y Latinoamérica, la epidemiología, los mecanismos fisiopatológicos, el proceso diagnóstico y el tratamiento de la hipertensión pulmonar en la enfermedad renal crónica.

Coccidioidomycosis among cast and crew members at an outdoor television filming event--California, 2012.

In March 2013, the California Department of Public Health (CDPH) identified two Doctor's First Reports of Occupational Injury or Illness (DFRs) regarding Los Angeles County residents who had worked at the same jobsite in January 2012 and had been evaluated for possible work-associated coccidioidomycosis (valley fever). Occupational exposure to Coccidioides, the causative fungi, typically is associated with soil-disrupting activities. The physicians noted that both workers were cast or crew members filming a television series episode, and the site of possible exposure was an outdoor set in Ventura County, California. On the basis of their job titles, neither would have been expected to have been engaged in soil-disrupting activities. Los Angeles County Department of Public Health (LACDPH) conducted an outbreak investigation by using CDPH-provided occupational surveillance records, traditional infectious disease surveillance, and social media searches. This report describes the results of that investigation, which identified a total of five laboratory-confirmed and five probable cases linked to this filming event. The employer and site manager were interviewed. The site manager stated that they would no longer allow soil-disruptive work at the site and would incorporate information about the potential risk for Coccidioides exposure onsite into work contracts. Public health professionals, clinicians, and the television and film industry should be aware that employees working outdoors in areas where Coccidioides is endemic (e.g., central and southern California), even those not engaged in soil-disruptive work, might be at risk for coccidioidomycosis.

Outbreak of bloodstream infections associated with multiuse dialyzers containing O-rings.

This report details an outbreak investigation conducted by the Los Angeles County Department of Public Health of 3 cases of bacterial infection among patients receiving hemodialysis who were treated at the same dialysis center in 2011. Improper disinfection of reusable dialyzers was hypothesized as the source of transmission.

Population-based incidence of carbapenem-resistant Klebsiella pneumoniae along the continuum of care, Los Angeles County.

OBJECTIVE: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant pathogen associated with higher mortality, longer hospital stays, and increased costs. CRKP was thought to be sporadic in Los Angeles County (LAC); however, the actual incidence is unknown. To address this, LAC declared CRKP a laboratory-reportable disease on June 1, 2010. DESIGN: Laboratory-based community-wide surveillance. PATIENTS: Any individual who was identified as CRKP positive. CRKP was defined as a K. pneumoniae isolate resistant to all carbapenems by 2010 Clinical and Laboratory Standards Institute criteria. METHODS: Laboratory directors of 102 LAC acute care hospitals (ACHs) and 5 reference laboratories were to submit susceptibility testing results for all CRKP-positive specimens. Positive specimens from the same patient within the same calendar month of previous culture were excluded. RESULTS: A total of 814 reports were received from June 1, 2010, through May 31, 2011, from 69 laboratories; 675 (83%) met the case definition. Cases were reported from ACHs (387 [57%]), long-term ACHs (LTACs; 231 [34%]), and skilled nursing facilities (57 [8%]); an outbreak in 1 LTAC was identified. The pooled mean incidence rate in LAC ACHs and LTACs was 0.46 per 1,000 patient-days; the rate in LTACs (2.54 per 1,000 patient-days) was higher than that in ACHs (0.31 per 1,000 patient-days; P < .001). Sixty-five individuals had multiple incidences, accounting for 147 case reports. CONCLUSION: CRKP is more present in LAC than suspected. Rates were consistently higher in LTACs than in ACHs. Heightened awareness of this problem is needed in all LAC healthcare facilities, as patients access services along the continuum of care.

[Two clinical cases of sporadic lymphangioleiomyomatosis]. / Linfangioleiomiomatosis esporádica. Dos casos clínicos.

Lymphangioleiomyomatosis (LAM) is a rare lung disease of unknown etiology, described since 1918 associated with tuberous sclerosis complex (TSC-LAM) and are reported sporadically (S-LAM). It is classified within the group of interstitial lung diseases (ILD) and currently the European Respiratory Society (ERS) has published guidelines for diagnosis and treatment. The objective is to evaluate the clinical presentation of two patients, evolution, management, and review of current treatment. Both patients admitted in our hospital for examination, presenting with spontaneous pneumothorax. Their CT scan shows characteristic cystic lesions and thoracotomy with lung biopsy was performed because lack of expansion and to confirming the diagnosis. Despite the controversy about the optimal management of these patients, there is evidence about the use of progesterone routinely in patients with rapid deterioration of respiratory function when it was provided for a period of at least 12 months. Due to the rareness of the disease, it requires a patient registry to evaluate the use of experimental drugs or include them in research protocols to improve their prognosis.

Outbreak of acute hepatitis B virus infections associated with podiatric care at a psychiatric long-term care facility.

BACKGROUND: Effective measures exist to prevent health care-associated hepatitis B virus (HBV) transmission, yet outbreaks continue to occur. In 2008, the Los Angeles County Department of Public Health identified an outbreak of HBV infections among psychiatric long-term care facility residents. METHODS: Residents underwent HBV serologic testing and were classified as acutely infected, chronically infected, susceptible, or immune. Persons residing in the facility during 2008 were enrolled in a retrospective cohort study to identify risk factors for acute HBV infection. We assessed infection control practices at the facility. RESULTS: Nine of 81 residents (11%) enrolled in the cohort study had acute HBV infection. Five of 15 residents (33%) undergoing podiatric care on a single day subsequently developed acute infection (rate ratio, 4.33; 95% confidence interval, 1.18-15.92). Infection control observations of the consulting podiatrist revealed opportunities for cross-contamination of instruments with blood. Other potential health care and behavioral modes of transmission were identified as well. Residents were offered HBV vaccination, and infection control recommendations were implemented by the podiatrist and facility. CONCLUSIONS: Of the multiple potential transmission modes identified, exposure to HBV during podiatry was likely the dominant mode in this outbreak. Long-term care facilities should ensure compliance with infection control standards among staff and consulting health care providers.

Differences between tight and loose cultures: a 33-nation study.

With data from 33 nations, we illustrate the differences between cultures that are tight (have many strong norms and a low tolerance of deviant behavior) versus loose (have weak social norms and a high tolerance of deviant behavior). Tightness-looseness is part of a complex, loosely integrated multilevel system that comprises distal ecological and historical threats (e.g., high population density, resource scarcity, a history of territorial conflict, and disease and environmental threats), broad versus narrow socialization in societal institutions (e.g., autocracy, media regulations), the strength of everyday recurring situations, and micro-level psychological affordances (e.g., prevention self-guides, high regulatory strength, need for structure). This research advances knowledge that can foster cross-cultural understanding in a world of increasing global interdependence and has implications for modeling cultural change.

Hospital methicillin-resistant Staphylococcus aureus active surveillance practices in Los Angeles County: Implications of legislation-based infection control, 2008.

Pending California legislation prompted an on-line survey of methicillin-resistant Staphylococcus aureus (MRSA) active surveillance practices administered to infection preventionists of all 102 acute care licensed hospitals in Los Angeles County. We describe reported surveillance methods. Ninety-six hospitals responded with 41% performing MRSA active surveillance. Comments indicated resistance to implementation of active surveillance because its benefits remain controversial.