Safe practices in Intensive Care Medicine, is zero risk possible?

Incidents related to patient safety are a problem of great impact in Intensive Care Medicine (ICM). Multiple strategies have been developed to identify them, analyze, and develop policies aim at reducing their incidence and minimizing their effects and consequences. The development of a safety culture, an adequate organizational and structural design of the ICM, which contemplates the implementation of effective safe practices, with a provision of human resources adjusted to the care activity carried out and the periodic analysis of the different events and their factors, will allow us to bring the risk of critical patient care closer to zero, as would be desirable.

Cranial-Vertebral-Maxillary Morphological Integration in Down Syndrome.

Background: Morphological integration refers to the tendency of anatomical structures to show correlated variations because they develop in response to shared developmental processes or function in concert with other structures. The objective of this study was to determine the relationships between the dimensions of different cranial-cervical-facial structures in patients with Down syndrome (DS). Methodology: The study group consisted of 41 individuals with DS who had undergone cone-beam computed tomography (CBCT) at the Dental Radiology Unit of the University of Santiago de Compostela (Spain). In the historical archive of this same unit, 41 CBCTs belonging to individuals with no known systemic disorders or severe malformations of the maxillofacial region were selected, forming an age and sex-matched control group. Twenty-nine measurements were performed on each participant's CBCT images, which were grouped into three blocks: atlantoaxial dimensions, craniovertebral dimensions and cephalometric dimensions. To determine whether there were significant differences between the dimensions obtained in the DS and control groups, we applied multiple analysis of variance and linear discriminant analysis tests. The analysis of the association between blocks (in pairs) was performed with the canonical correlation analysis test. Results: The dimensions evaluated in the three blocks of variables of individuals with DS differ significantly from those of nonsyndromic controls (p < 0.001). The highest discriminative capacity to identify controls and patients with DS was obtained with the cephalometric dimensions (87.5%). With regard to the association between blocks (two-by-two measurements), we found no significant relationship in the DS group. However, we confirmed a statistically significant correlation between all pairs of blocks of variables in the controls, especially between the atlantoaxial and cephalometric dimensions (p < 0.001) and between the craniovertebral and cephalometric dimensions (p < 0.001). Conclusions: Our results confirm a very poor morphological integration of the cranial-cervical-maxillary complex in individuals with DS. This finding reinforces the proposal that gene overload enhances the channeling process.

Probing single-tooth dental implants with and without prostheses: a cross-sectional study comparing healthy and peri-implant mucositis sites.

AIM: To evaluate differences in probing depth (PPD) with and without a prosthesis in implants without interproximal bone loss (IBL). Secondarily, to assess whether the difference in PPD measured with and without the crown was affected by diagnosis or implant location. MATERIALS AND METHODS: A cross-sectional study was conducted in patients with a single screw-retained implant-supported crown in the posterior area, without IBL. PPD and was assessed before and after crown removal. A subgroup analysis compared healthy vs. mucositis implants and premolar vs. molar locations. RESULTS: In the 62 implants analysed (23 healthy and 39 with mucositis), the PPD was 1.15 mm (SD = 1.24 mm) deeper without the prosthesis than with it (p < .001). This difference was independent of the implant location (p > .05) except for buccal sites (p = .048). The mean PPD difference for implants with mucositis was 0.95 mm (SD = 1.19 mm; p < .001) while healthy implants had a mean PPD variation of 1.47 mm (SD = 1.29 mm; p < .001). CONCLUSION: The presence of prosthesis in single-tooth implants in the posterior area without IBL seems to lead to an underestimation of PPD that appears to be significant in implants diagnosed with mucositis, although the difference is even greater in healthy implants. Further studies are needed to confirm these findings.

Epidemiology and Changes in Mortality of Sepsis After the Implementation of Surviving Sepsis Campaign Guidelines.

PURPOSE: To determine the epidemiology and outcome of severe sepsis and septic shock after 9 years of the implementation of the Surviving Sepsis Campaign (SSC) and to build a mortality prediction model. METHODS: This is a prospective, multicenter, observational study performed during a 5-month period in 2011 in a network of 11 intensive care units (ICUs). We compared our findings with those obtained in the same ICUs in a study conducted in 2002. RESULTS: The current cohort included 262 episodes of severe sepsis and/or septic shock, and the 2002 cohort included 324. The prevalence was 14% (95% confidence interval: 12.5-15.7) with no differences to 2002. The population-based incidence was 31 cases/100 000 inhabitants/year. Patients in 2011 had a significantly lower Acute Physiology and Chronic Health Evaluation II (APACHE II; 21.9 ± 6.6 vs 25.5 ± 7.07), Logistic Organ Dysfunction Score (5.6 ± 3.2 vs 6.3 ± 3.6), and Sequential Organ Failure Assessment (SOFA) scores on day 1 (8 ± 3.5 vs 9.6 ± 3.7; P < .01). The main source of infection was intraabdominal (32.5%) although microbiologic isolation was possible in 56.7% of cases. The 2011 cohort had a marked reduction in 48-hour (7% vs 14.8%), ICU (27.2% vs 48.2%), and in-hospital (36.7% vs 54.3%) mortalities. Most relevant factors associated with death were APACHE II score, age, previous immunosuppression and liver insufficiency, alcoholism, nosocomial infection, and Delta SOFA score. CONCLUSION: Although the incidence of sepsis/septic shock remained unchanged during a 10-year period, the implementation of the SSC guidelines resulted in a marked decrease in the overall mortality. The lower severity of patients on ICU admission and the reduced early mortality suggest an improvement in early diagnosis, better initial management, and earlier antibiotic treatment.

Effect of implantoplasty on fracture resistance and surface roughness of standard diameter dental implants.

OBJECTIVE: To assess the effect of implantoplasty on the fracture resistance, surface roughness, and macroscopic morphology of standard diameter (4.1 mm) external connection dental implants. MATERIALS AND METHODS: An in vitro study was conducted in 20 screw-shaped titanium dental implants with an external connection. In 10 implants, the threads and surface were removed and polished with high-speed burs (implantoplasty), while the remaining 10 implants were used as controls. The final implant dimensions were recorded. The newly polished surface quality was assessed by scanning electron microscopy (SEM) and by 3D surface roughness analysis using a confocal laser microscope. Finally, all the implants were subjected to a mechanical pressure resistance test. A descriptive analysis of the data was made. Also, Student's t tests were employed to detect differences regarding the compression tests. RESULTS: Implantoplasty was carried out for a mean time of 10 min and 48 s (standard deviation (SD) of 1 min 22 s). Macroscopically, the resulting surface had a smooth appearance, although small titanium shavings and silicon debris were present. The final surface roughness (Sa values 0.1 ± 0.02 µm) was significantly lower than that of the original (0.75 ± 0.08 µm Sa ) (p = .005). There was minimal reduction in the implant's inner body diameter (0.19 ± 0.03 mm), and no statistically significant differences were found between the test and control implants regarding the maximum resistance force (896 vs 880 N, respectively). CONCLUSIONS: Implantoplasty, although technically demanding and time-consuming, does not seem to significantly alter fracture resistance of standard diameter external connection implants. A smooth surface with Sa values below 0.1 µm can be obtained through the use of silicon polishers. A larger sample is required to confirm that implantoplasty does not significantly affect the maximum resistance force of standard diameter external connection implants.

Mortality Reduction and Long-Term Compliance with Surviving Sepsis Campaign: A Nationwide Multicenter Study.

PURPOSE: To determine the long-term degree of compliance with the Surviving Sepsis Campaign (SSC) bundles and related outcomes after an educational program in septic patients admitted to a network of intensive care units (ICU). METHODS: Prospective, observational, multicenter study in several ICUs during a 5-month period for evaluating the degree of compliance with the SSC bundles of resuscitation in the first 6 h (B6H) and management in the following 24 h (B24H). We compared the findings with those from a historical cohort at the same ICUs after an educational program (EDUSEPSIS) 5 years earlier. RESULTS: The study cohort comprised 231 episodes of severe sepsis and the historical cohort included 217. In the current cohort, we found a better compliance with B6H compared with the historical cohort (27.7% vs. 9.7%, P < 0.001), and lower compliance with B24H (4.3% vs. 12.9%, P < 0.001). ICU and in-hospital mortalities were reduced from 37.3% to 27.1% (P = 0.02) and from 45.3% to 36.7% (P = 0.06), respectively. This reduction occurred linearly with the number of B6H items completed (P for trend <0.001). All B6H measures were individually associated with lower ICU mortality. Measurement of plasma lactate, blood cultures, and administration of broad-spectrum antibiotics were associated with lower in-hospital mortality. No benefit was observed regarding B24H. CONCLUSIONS: Our study confirmed that an educational campaign aimed at early recognition and management of patients with severe sepsis improves compliance with management recommendations and hospital survival in the long term.

Accuracy of periapical radiography in assessing bone level in implants affected by peri-implantitis: a cross-sectional study.

AIM: The aim of this study was to assess the accuracy of periapical radiography in measuring peri-implant bone levels. MATERIALS AND METHODS: Twenty-five subjects with 46 implants in need of surgical treatment for peri-implantitis were included in this cross-sectional study. Prior to surgery, periapical radiographs were taken, a prediction of type of defect was made and radiographic peri-implant bone levels (RxBL) were determined at the mesial and distal aspects. Intra-operatively, the peri-implant bone level (SurgBL) was assessed mesially, distally, buccally and orally and the type of defect was recorded. A paired t-test was applied to detect differences between inter-proximal RxBL and SurgBL. ANOVA was used to compare SurgBL at different circumferential positions. RESULTS: The mean inter-proximal RxBL was 4.0 ± 2.2 mm and the mean inter-proximal SurgBL was 5.3 ± 2.3 mm. The difference between RxBL and SurgBL was statistically significant (p = 0.014). There were no significant differences in SurgBL at the mesial, distal, buccal and oral aspects (p > 0.05). CONCLUSIONS: The intra-operatively measured peri-implant bone levels were more apical than the radiographic bone levels. The intra-operatively assessed peri-implant bone levels (SurgBL) were similar at all the circumferential positions around the implant.

[Variant phenotype of Lesch-Nyhan syndrome]. / Fenotipo variante del síndrome de Lesch-Nyhan.

BACKGROUND AND OBJECTIVE: Lesch-Nyhan syndrome (LNS) and LNS variants are due to mutations in the HPRT1 gene causing HPRT enzymatic activity deficiency. We report a patient presenting a variant phenotype and a major genetic defect. The mutation has been previously reported as always associated with complete Lesch-Nyhan phenotype. PATIENT AND METHODS: We analyzed the presence of complete HPRT mRNA in this patient, in two patients with the complete Lesch Nyhan syndrome phenotype, and in control subjects. RESULTS: We found a minor amount of normal HPRT mRNA in the present patient but also in the two patients with splice mutation and the complete Lesch Nyhan syndrome phenotype. CONCLUSIONS: To our knowledge, this patient is the first report of a major genetic defect, with no detectable enzymatic activity, and a partial HPRT deficiency phenotype. Our results question the hypothesis of a normally spliced HPRT cDNA as the sole cause of the patient partial phenotype.