Poisoning among the elderly. / Intoxicaciones en la tercera edad.

OBJECTIVES: Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals. METHODS: Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital. RESULTS: A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4). CONCLUSIONS: The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

The unresolved riddle of glucocorticoid withdrawal.

Glucocorticoid (GC) therapy is the most common cause of adrenal insufficiency (AI). The real prevalence of AI after GC is unknown but it could involve more than 30% of patients. Some gene variation has been associated with the variability of hypothalamic-pituitary-adrenal (HPA) axis and this issue could contribute to the individual variation of adrenal function after GC treatment. Symptoms and signs of AI are nonspecific and frequently the diagnosis is delayed. Dosage, duration of treatment, administration route and serum cortisol value are not completely useful to predict AI. Clinical estimation of HPA suppression is difficult and biochemical testing is needed to confirm the diagnosis of AI. The different tapering regimens are based on a very low quality of evidence and considering the sizable individual variation, it is improbable that future research will find a secure GC tapering schedule for all patients. The aim of this review is to address the most important aspects in management of GC withdrawal in light of current knowledge.

Long-Term Mortality After Pneumonia in Cardiac Surgery Patients: A Propensity-Matched Analysis.

BACKGROUND: The role that intensive care unit (ICU)-acquired pneumonia plays in the long-term outcomes of cardiac surgery patients is not well known. This study examined the association of pneumonia with in-hospital mortality and long-term mortality after adult cardiac surgery. METHODS: A total of 2750 patients admitted to our ICU after cardiac surgery from January 2003 to December 2009 are the basis for this observational study. Patients who developed ICU-acquired pneumonia were matched with patients without it in a 1:2 ratio. The matching criteria were age, urgent or scheduled surgery, surgical procedure, and the propensity score for pneumonia. Multiple regression analysis was used to find predictors of hospital mortality. The relationship between pneumonia and long-term survival was analyzed with Kaplan-Meier survival estimates and a risk-adjusted Cox proportional regression model for patients discharged alive from hospital. RESULTS: Pneumonia was diagnosed in 32 (1.2%) patients and there were 19 cases per 1000 days of mechanical ventilation. Patients with pneumonia had a significantly higher hospital mortality rate (28% vs 6.2%, P = .003) and a higher mortality at the end of follow-up (53% vs 19%, P < .0001) than those without it. Regression analysis showed that pneumonia was a strong predictor of hospital mortality. Five-year survival was as follows: pneumonia, 62%; control, 81%; and cohort patients, 91%. The Cox model showed that, after adjusting for confounding factors, patients with pneumonia (hazard ratio = 3.96, 95% confidence interval [CI]: 1.41-11.14) had poorer long-term survival. CONCLUSION: Pneumonia remains a serious complication in patients operated for cardiac surgery and is associated with increased hospital mortality and reduced long-term survival.

Patient safety certification in a Department of Intensive Care Medicine: our experience with standard UNE 179003:2013.

Systematic and structured methods must be used to ensure that healthcare risks are effectively managed. Spanish standard UNE 179003:2013 provides healthcare organizations with a framework and a systematic protocol for managing patient safety from a clinical and organizational perspective. Furthermore, it is useful in securing an efficient balance among health risk, health outcomes and costs. The UNE 179003:2013 certifies that a clinical service complies with rules and operating procedures aimed at reducing the incidence of adverse events. It also requires mandatory continuous improvement, given that the standard entails frequent monitoring of the risk management system through periodic audits. The aims of this paper are to describe the UNE 179003:2013 certification process in an Intensive Care Unit, propose a risk management program for critical patients, and offer some recommendations regarding its implementation.

[Red cell transfusion and long-term survival in non-complicated heart surgery]. / Transfusión de hematíes y supervivencia a largo plazo en la cirugía cardíaca no complicada.

OBJECTIVE: A study was made to explore the possible association between the perioperative transfusion of 1 - 2 red blood cell units and in-hospital morbidity, 30-day mortality, and long-term survival in patients undergoing heart surgery. DESIGN: A prospective observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: All patients over 17 years of age that underwent heart surgery and were admitted to the ICU between November 2002 and December 2009 were included. Those patients who did not (n=703) and those who did (n=959) receive the perioperative transfusion of 1 - 2 red blood cell units were assessed. STUDY ENDPOINTS: The endpoints were the effect of transfusion on both hospital morbidity and on 30-day mortality. In addition, all patients discharged alive from hospital until 31 December 2011 were subjected to follow-up. The association between transfusion and survival was assessed by means of the Kaplan-Meier method. Cox proportional hazards models were used to assess factors associated with long-term survival. RESULTS: The frequency of both cardiac and non-cardiac perioperative complications was higher in patients receiving transfusion. The 30-day mortality rate was higher in those who received transfusion (1% vs 0.1%, P=.02). Preoperative anemia was associated with a more intensive use of transfusion. Red blood cell transfusion was not found to be a risk factor for long-term mortality (hazar ratio=1.4, 95%CI 0.9-2.1). CONCLUSIONS: The perioperative transfusion of 1 - 2 red blood cell units in patients undergoing heart surgery increases both hospital morbidity and the 30-day mortality rate, but does not increase long-term mortality.

Poisoning among the elderly.

OBJECTIVES: Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals. METHODS: Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital. RESULTS: A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4). CONCLUSIONS: The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Incidence, patterns of care and prognostic factors for outcome of gastroenteropancreatic neuroendocrine tumors (GEP-NETs): results from the National Cancer Registry of Spain (RGETNE).

BACKGROUND: Neuroendocrine tumors (NETs) are an unusual family of neoplasms with a wide and complex spectrum of clinical behavior. Here, we present the first report of a National Cancer Registry of gastroenteropancreatic neuroendocrine tumors from a Southern European country. PATIENTS AND METHODS: Data was provided online at www.retegep.net by participating centers and assessed for internal consistency by external independent reviewers. RESULTS: The study cohort comprised 907 tumors. The most common tumor types were carcinoids (55%), pancreatic nonfunctional tumors (20%), metastatic NETs of unknown primary (9%), insulinomas (8%) and gastrinomas (4%). Forty-four percent presented with distant disease at diagnosis, most often those from small intestine (65%), colon (48%), rectum (40%) and pancreas (38%), being most unusual in appendix primaries (1.3%). Stage at diagnosis varied significantly according to sex, localization of primary tumor, tumor type and grade. Overall 5-year survival was 75.4% (95% confidence interval 71.3% to 79.5%) and was significantly greater in women, younger patients and patients with hormonal syndrome and early stage or lower grade tumors. Prognosis also differed according to tumor type and primary tumor site. However, stage and Ki-67 index were the only independent predictors for survival. CONCLUSION: This national database reveals relevant information regarding epidemiology, current clinical practices and prognosis of NETs in Spain, providing valuable insights that may contribute to understand regional disparities in the incidence, patterns of care and survival of this heterogeneous disease across different continents and countries.

Occupational exposure to endocrine-disrupting chemicals and other parental risk factors in hypospadias and cryptorchidism development: a case-control study.

AIM OF THE STUDY: Endocrine-disrupting chemicals (EDCs) are exogenous agents that are capable of altering the endocrine system functions, including the regulation of developmental processes. The aim of this study was to investigate the association between EDC exposure and other parental factors in the etiology of hypospadias and cryptorchidism. METHODS: A case-control study was conducted. Cases (n = 210) were infants aged between 6 months and 14 years diagnosed with hypospadias or cryptorchidism who attended the authors' hospital over a period of 18 months, and controls (n = 210) were infants within the same range of age and without any urological disorders who attended the outpatient clinic of the same hospital during the same time period. Their selection was independent of exposures. Data on parental occupational exposure to EDCs and other sociodemographic variables were collected through face-to-face interviews and systematically for both cases and controls. Crude and adjusted odds ratios (ORs) were estimated to control for confounding with their 95% confidence interval (CI) by means of logistic regressions. Specifically, three final models of a dichotomous outcome were constructed: one for cryptorchidism, one for hypospadias, and the third considering both malformations together. The Hosmer-Lemeshow test was used to assess the goodness of fit of the models. Their discriminatory accuracy (DA) was ascertained by estimating their areas under the receiver operating characteristic curves area under the curve (AUC) along with their 95% CI. RESULTS: Associations were found between advanced maternal age (OR adjusted = 1.82; 95% CI: 1.14-2.92), mother's consumption of anti-abortives (OR = 5.40; 95% CI: 1.40-38.5) and other drugs (OR = 2.02; 95% CI: 1.31-3.16) during pregnancy, maternal and paternal occupational exposure to EDCs (OR = 4.08; 95% CI: 2.03-8.96 and OR = 3.90; 95% CI: 2.41-6.48, respectively), fathers smoking (OR = 2.0; 95% CI: 1.33-2.99), and fathers with urological disorders (OR = 2.31; 95% CI: 1.15-4.90). Maternal and paternal high educational level could be protective of cryptorchidism (OR = 0.47; 95% CI: 0.28-0.76 and OR = 0.63; 95% CI: 0.42-0.93, respectively). The DA of the models for the whole sample (AUC = 0.75; 95% CI: 0.70-0.79) for cryptorchidism (AUC = 0.76; 95% CI: 0.71-0.82) and for hypospadias (AUC = 0.75; 95% CI: 0.69-0.81) was moderately high. CONCLUSIONS: Advanced age, some parental occupational exposure to EDCs, some drug consumption, smoking, and the father's history of urological disorders may increase risk and predict the developments of these malformations. Studies with higher samples sizes are needed to assess associations between individual EDC occupational exposures and drugs and these malformations.

[Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital]. / Mortalidad de las complicaciones postoperatorias (failure to rescue) tras cirugía cardiaca en un hospital universitario.

OBJECTIVE: This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival. METHODS: The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival. RESULTS: Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26). CONCLUSIONS: The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9).

Distribution of neuropeptide Y-like immunoreactivity in the brain of the lizard Gallotia galloti.

The distribution of neuropeptide Y (NPY)-like immunoreactivity was studied in the brain of the lizard Gallotia galloti, in order to gain insight into the comparative topography of this peptide. Antisera against both NPY and its C-terminal flanking peptide (C-PON) were used, demonstrating a general coexistence of both peptides, as described in other vertebrates. Most NPY-like immunoreactive (NPY-LI) cell bodies were observed in the telencephalon, specifically in various olfactory structures, all cortices, septum, basal ganglia (except for the globus pallidus), the nucleus of the diagonal band of Broca, the amygdaloid complex, and the bed nucleus of the anterior commissure. NPY-LI cells were also seen in the preoptic and hypothalamic regions and the dorsal thalamus (mainly in the perirotundal belt), as well as in the mesencephalic tegmentum (in the ventral tegmental area, the substantia nigra, and the retrorubral area). NPY-LI fibers and terminals were widely distributed in the brain. All visual and auditory neuropiles were densely innervated. Specially dense plexuses were seen in the nucleus accumbens, the ventral pallidum, the suprachiasmatic and ventromedial hypothalamic nuclei, the nucleus medialis thalami, the left habenula, and the central nucleus of the torus semicircularis. Our analysis shows that the distribution of NPY-like immunoreactivity in the forebrain of Gallotia largely resembles that of other vertebrates, whereas differences are mainly observed in the brainstem. The widespread distribution of NPY in the lizard brain suggests several modulatory functional roles, either in local-circuit systems of the forebrain, or in various limbic, neuroendocrine, and sensory pathways.

Immunohistochemical investigation of gamma-aminobutyric acid ontogeny and transient expression in the central nervous system of Xenopus laevis tadpoles.

The ontogeny of the gamma-aminobutyric acid (GABA)-positive neurons in the brain of Xenopus laevis tadpoles was investigated by means of immunohistochemistry, using specific antibodies both against GABA and its biosynthetic enzyme, glutamate decarboxylase (GAD). The results obtained with the two antisera were comparable. The GABA system differentiates very early during development. At stages 35/36, numerous GABA-positive neurons were seen throughout the prosencephalon and formed two main bilateral clusters within the lateral walls of the forebrain that ran caudally toward the hindbrain. Other GABA-immunolabeled cell bodies, together with a conspicuous network of GABAergic fibers, were seen in the posterior hypothalamus. In the spinal cord, the lateral marginal zone was GABA-positive, as were Rohon-Beard neurons, interneurons, and Kolmer-Agdhur cells. A very rich GABA innervation was observed in the pars intermedia of the pituitary. At stage 50, plentiful immunopositive neurons and fibers were found in the telencephalic hemispheres, the diencephalon, and the mesencephalon (optic tectum and tegmentum). By stage 54, the number of GABA-immunoreactive neurons in the posterior hypothalamus had decreased, so that, at stage 58, there were very few GABA-labeled cell bodies in the dorsolateral walls of the infundibulum, despite a strong GABAergic innervation within the median eminence and the pars intermedia. From stage 58 to stage 66, the distribution pattern was very similar to that described in the adult X. laevis and in other amphibian species. These results point to transient GABA expression within the hypothalamus, possibly related to either 1) a naturally occurring cell death or 2) a phenotypic switch.

Involvement of retinohypothalamic input, suprachiasmatic nucleus, magnocellular nucleus and locus coeruleus in control of melanotrope cells of Xenopus laevis: a retrograde and anterograde tracing study.

The amphibian Xenopus laevis is able to adapt the colour of its skin to the light intensity of the background, by releasing alpha-melanophore-stimulating hormone from the pars intermedia of the hypophysis. In this control various inhibitory (dopamine, gamma-aminobutyric acid, neuropeptide Y, noradrenaline) and stimulatory (thyrotropin-releasing hormone and corticotropin-releasing hormone) neural factors are involved. Dopamine, gamma-aminobutyric acid and neuropeptide Y are present in suprachiasmatic neurons and co-exist in synaptic contacts on the melanotrope cells in the pars intermedia, whereas noradrenaline occurs in the locus coeruleus and noradrenaline-containing fibres innervate the pars intermedia. Thyrotropin-releasing hormone and corticotropin-releasing hormone occur in axon terminals in the pars nervosa. In the present study, the neuronal origins of these factors have been identified using axonal tract tracing. Application of the tracers 1,1'dioctadecyl-3,3,3',3' tetramethyl indocarbocyanine and horseradish peroxidase into the pars intermedia resulted in labelled neurons in two brain areas, which were immunocytochemically identified as the suprachiasmatic nucleus and the locus coeruleus, indicating that these areas are involved in neural inhibition of the melanotrope cells. Thyrotropin-releasing hormone and corticotropin-releasing hormone were demonstrated immunocytochemically in the magnocellular nucleus. This area appeared to be labelled upon tracer application into the pars nervosa. This finding is in line with the idea that corticotropin-releasing hormone and thyrotropin-releasing hormone stimulate melanotrope cell activity after diffusion from the neural lobe to the pars intermedia. After anterograde filling of the optic nerve with horseradish peroxidase, labelled axons were traced up to the suprachiasmatic area where they showed to be in contact with suprachiasmatic neurons. These neurons showed a positive reaction with anti-neuropeptide Y and the same held for staining with anti-tyrosine hydroxylase. It is suggested that a retino-suprachiasmatic pathway is involved in the control of the melanotrope cells during the process of background adaptation.

Multiple sources of the pituitary pars intermedia innervation in amphibians: a DiI retrograde tract-tracing study.

Afferent projections to the pituitary pars intermedia were studied using the DiI tract-tracing technique in two amphibian species, the urodelan Triturus carnifex, and the anuran Rana esculenta. After DiI crystal application into the pituitary intermediate lobe, in both species cells were retrogradely labeled in the preoptic nucleus, in the supra- and retro-chiasmatic hypothalamus and in the brainstem (especially in the area indicated as locus coeruleus). The findings are discussed in relation to data on the neurochemical nature of the innervation of the pars intermedia in amphibians.

Carnosine in the brain and olfactory system of amphibia and reptilia: a comparative study using immunocytochemical and biochemical methods.

The pattern of distribution of carnosine-like immunoreactivity and its relation to glial fibrillary acidic protein immunoreactivity have been studied in two lizards (Gallotia galloti and Tarentola delalandii) and in two anuran amphibians (Rana esculenta and Xenopus laevis) using immunocytochemical techniques. Biochemical data obtained by paper electrophoresis show that the dipeptides carnosine and homocarnosine are both present in the brain of all the species examined. In the central nervous system of both anurans and reptilians, carnosine immunoreactivity is localized in glial cells. An important species difference is, however, seen in the olfactory system since primary olfactory neurons and their processes extending to the olfactory bulb are carnosine positive in reptiles, whereas they are not immunostained in anurans. Thus, the cellular distribution of carnosine immunoreactivity in reptilians is very similar to that observed in birds and mammals and is distinct from that seen in amphibia.

Gonadal-GABAergic interaction is an important factor involved in photoperiod-induced 2-[125I] iodomelatonin binding changes in the Japanese quail brain.

The type of mechanism(s) by which melatonin alone and/or through the intervention of other putative neurotransmitters is able to control circadian rhythms remains unresolved. Comparison of 2-[125I]iodomelatonin binding pattern in the brain of castrated and gonadally intact Japanese quail (Coturnix japonica), using quantitative receptor autoradiography, displayed that the combination of the intact gonadal condition and a long-day (16L:8D) photostimulatory schedule is responsible for major binding changes. In fact, high and low binding levels were obtained in the suprachiasmatic area and nucleus ectomamillaris (p < 0.01) and in the nucleus preopticus anterior and paleostriatum primitivum (p < 0.001), respectively. A gonadal modulatory role was not always evident in all brain areas as revealed by long-day photic cycles producing diminished (p < 0.01) binding levels in the anterior neostriatum and the nucleus rotundus of both castrated and gonadally intact animals, although elevated values were also found in the substantia grisea centralis (p < 0.05) of the same animals. Saturation binding studies revealed that gonadal and/or photic effects induce alterations in the number of binding sites, whereas the affinity constant varied only in some hypothalamic sites. Testing of GABAergic activity on 2-[125I] iodomelatonin binding levels showed that this inhibitory neurotransmitter was responsible for increasing low receptor values. Moreover, GABA-dependent influences were shown to be mediated via a GABAA receptor subtype since bicuculline (specific antagonist of this site) inhibited the elevated GABA-induced melatonin binding levels in the above brain sites of the gonadally intact quail exposed to both photoperiod cycles. Even in this case, melatonin binding changes were due to the variations in the number of binding sites. The apparent GABAergic-gonadal influence resulting in changes of the 2-[125I] iodomelatonin binding values, under the different photic conditions, provides evidences of other probable neural mechanisms that entrain circadian rhythmicity in neuroendocrine activities and in sociosexual behaviors.

Comparative study of glial fibrillary acidic protein (GFAP)-like immunoreactivity in the retina of some representative vertebrates.

A polyclonal glial fibrillary acidic protein (GFAP) antiserum was used to study the distribution of GFAP-like immunoreactivity in the retina of adult vertebrates (teleosts, amphibians, reptiles, birds and mammals). GFAP-positive Müller cells were demonstrated in all the species studied, although with different degrees and patterns of immunoreactivity. In nonmammalian vertebrates, Müller cells were the only immunoreactive retinal elements. The staining was located throughout the retina of the species examined, with the exception of the rabbit, which exhibited regional variability in the expression of GFAP. The data indicate that GFAP expression in retinal Müller cells is a common feature of a wide variety of adult vertebrate species.

Dihydronicotinamide adenine dinucleotide diaphorase in the central nervous system of the crested newt.

By using a histochemical procedure, the distribution of neurons containing dihydronicotinamide adenine dinucleotide diaphorase (NADPHd) was examined in the brain, retina and olfactory epithelium of the urodele amphibian Triturus carnifex. Positive nerve fibers and terminals were observed throughout the brain and cell bodies were seen within the telencephalon, optic tectum, brain stem, cerebellum and spinal cord. In the retina, NADPHd labeling was localized in the outer segment of photoreceptors and in some amacrine cells as well as in the outer and inner plexiform layers. In the olfactory epithelium, NADPHd labeling was found in the olfactory neurons. By comparing NADPHd distribution with nitric oxide synthase (NOS) immunoreactivity (using a polyclonal antiserum raised against mouse cerebellar NOS) it was found that NADPHd labeling and NOS immunoreaction patterns generally matched. The organization of NADPHd and NOS containing neurons in the central nervous system of the crested newt, which is simpler than in other vertebrates investigated, shows some peculiarities, such as the occurrence of NADPHD in the pinealocytes of the epiphysis, nucleus rubber of the brain stem and eminentia cerebellaris ventralis of the cerebellum.

[Identification and validation of prognostic factors in differentiated thyroid carcinoma]. / Identificación y validación de factores pronósticos del cáncer diferenciado de tiroides.

BACKGROUND: The aims of this study are to identify prognostic factors of differentiated thyroid carcinoma and to validate the application of prognostic classifications obtained by others studies to another population. PATIENTS AND METHODS: The survival of 208 patients with differentiated thyroid carcinoma (129 papillary and 79 follicular carcinoma) was calculated by the Kaplan-Meier method. The mean follow-up was 7.5 years (1-17.7). Cox-proportional hazard model was used for variables influencing on survival (Mantel-Cox method). In addition, the EORTC, AGES, AJC, AMES and DeGroot classifications were tested. RESULTS: The independent prognostic factors identified were patient age > 60 years, tumor size > 6 cm and the presence of distant metastases. The absence of poor prognostic factors defined the low risk group (153 patients, survival 97% at 17.7 years of follow-up). The application of the other prognostic classifications differentiated several risk groups not in accordance with those obtained in the initial population. CONCLUSIONS: In this series of patients with thyroid carcinoma the main prognostic factors were age, tumor size and the presence of distant metastases. However, there are pitfalls in applying the prognostic classifications of published studies to another population.

[Consensus conference on providing information of adverse events to patients and relatives]. / Conferencia de consenso sobre información de eventos adversos a pacientes y familiares.

OBJECTIVE: To develop recommendations regarding «Information about adverse events to patients and their families¼, through the implementation of a consensus conference. MATERIAL AND METHODS: A literature review was conducted to identify all relevant articles, the major policies and international guidelines, and the specific legislation developed in some countries on this process. The literature review was the basis for responding to a series of questions posed in a public session. A group of experts presented the best available evidence, interacting with stakeholders. At the end of the session, an interdisciplinary and multi-professional jury established the final recommendations of the consensus conference. RESULTS: The main recommendations advocate the need to develop policies and institutional guidelines in our field, favouring the patient adverse events disclosure process. The recommendations emphasize the need for the training of professionals in communication skills and patient safety, as well as the development of strategies for supporting professionals who are involved in an adverse event. The assessment of the interest and impact of specific legislation that would help the implementation of these policies was also considered. CONCLUSIONS: A cultural change is needed at all levels, nuanced and adapted to the specific social and cultural aspects of our social and health spheres, and involves all stakeholders in the system to create a framework of trust and credibility in which the processing of information about adverse events may become effective.

[Patient safety in management contracts]. / La seguridad del paciente en los contratos de gestión.

Patient safety is becoming commonplace in management contracts. Since our experience in patient safety still falls short of other clinical areas, it is advisable to review some of its characteristics in order to improve its inclusion in these contracts. In this paper opinions and recommendations concerning the design and review of contractual clauses on safety are given, as well as reflections drawn from methodological papers and informal opinions of clinicians, who are most familiar with the nuances of safe and unsafe practices. After reviewing some features of these contracts, criteria for prioritizing and including safety objectives and activities in them, and key points for their evaluation are described. The need to replace isolated activities by systemic and multifaceted ones is emphasized. Errors, limitations and improvement opportunities observed when contracts are linked to indicators, information and adverse event reporting systems are analysed. Finally, the influence of the rules of the game, and clinicians behaviour are emphasised.