The EPAGE guidelines are not an effective strategy for managing colonoscopies during the COVID-19 pandemic. / EPAGE no es una estrategia eficaz para la gestión de colonoscopias durante la pandemia por COVID-19.

INTRODUCTION: The pandemic caused by the SARS-CoV-2 virus has had a serious impact on the functioning of gastrointestinal endoscopy Units. The Asociación Española de Gastroenterología (AEG) and the Sociedad Española de Endoscopia Digestiva (SEED) have proposed the EPAGE guidelines for managing postponed colonoscopies. OBJECTIVE: To evaluate the EPAGE guidelines as a management tool compared to the immunologic faecal occult blood test (iFOBT) and compared to risk score (RS) that combines age, sex and the iFOBT for the detection of colorectal cancer (CRC) and significant bowel disease (SBD). METHODS: A prospective, single-centre study enrolling 743 symptomatic patients referred for a diagnostic colonoscopy. Each order was classified according to the EPAGE guidelines as appropriate, indeterminate or inappropriate. Patients underwent an iFOBT and had their RS calculated. RESULTS: The iFOBT (p<0.001), but not the EPAGE guidelines (p = 0.742), was an independent predictive factor of risk of CRC. The ROC AUCs for the EPAGE guidelines, the iFOBT and the RS were 0.61 (95% CI 0.49-0.75), 0.95 (0.93-0.97) and 0.90 (0.87-0.93) for CRC, and 0.55 (0.49-0.61), 0.75 (0.69-0.813) and 0.78 (0.73-0.83) for SBD, respectively. The numbers of colonoscopies needed to detect a case of CRC and a case of SBD were 38 and seven for the EPAGE guidelines, seven and two for the iFOBT, and 19 and four for a RS ≥5 points, respectively. CONCLUSION: The EPAGE guidelines, unlike the iFOBT, is not suitable for screening candidate patients for a diagnostic colonoscopy to detect CRC. The iFOBT, in combination with age and sex, is the most suitable strategy for managing demand for endoscopy in a restricted-access situation.

[Prescription appropriateness in elderly patients with polypharmacy in primary care: Cluster-randomized controlled trial PHARM-PC]. / Adecuación de la prescripción en pacientes mayores polimedicados en atención primaria. Ensayo clínico controlado aleatorizado por grupos PHARM-PC.

OBJECTIVES: To assess the effectiveness of a pharmacist-led systematic review of medications on: potentially inappropriate medications (PIM), health outcomes and costs. DESIGN: Prospective, open, controlled and cluster-randomized clinical trial. SETTING: Six primary care clinics from Balearic Islands. PARTICIPANTS: Forty-two clusters (21 per group), and 549 patients aged ≥65 years and ≥5 chronic medications were included; of which 277 were allocated to Intervention Group (IG) and 272 to Control Group (CG). Patients were excluded if they were: institutionalized, temporarily displaced, routinely monitored under private healthcare, or home care. INTERVENTION: PIM detection by the pharmacist using a combination of explicit and implicit methods; and communication of the most appropriate therapeutic strategies to the physician. MEASUREMENTS: Proportion of patients with PIM and mean number of PIM/patient (main outcomes); and morbidity, mortality, and costs (secondary outcomes) were assessed. STATISTICAL PLAN: Following an intention-to-treat approach, quantitative and qualitative outcomes variables were compared by T-Student and Chi-square tests, respectively. Results were providing as difference in proportions for qualitative outcomes and difference in means for quantitative outcomes with respective 95% confidence intervals (95% CI). RESULTS: After intervention, proportion of patients with PIM decreased by 13.7% (95% CI: 9.3; 18.2) more in IG than CG. Mean number of PIM/patient and mean cost of PIM/patient decreased by 0.43 (95% CI: 0.32; 0.54) and 72.11€ (95% CI: 26.15; 118.06) more in IG than CG, respectively. However, no statistically significant differences were observed in morbidity, mortality or costs of healthcare resources. CONCLUSIONS: PIM detection and recommendations provided by pharmacist could contribute to reduce significantly PIM and drug expenditure; but without reaching statistically significant differences in morbidity, mortality, and healthcare resources costs.

Periendoscopic management of antiplatelet therapy: Prospective evaluation of adherence to guidelines.

INTRODUCCIóN: Adherence to guidelines on the periendoscopic management of antiplatelet therapy (APT) has not been analyzed in detail. Our aim was to assess adherence to guidelines in patients referred to our Endoscopy Unit on a case-by-case basis, describing in detail the detected deviations and identifying areas of improvement. PATIENTS AND METHODS: Cross-sectional study of outpatients consecutively scheduled for an unsedated upper or lower gastrointestinal endoscopy between January and June 2015. Patients on anticoagulant therapy were excluded. RESULTS: 675 patients were evaluated, including 91 (13.5%) patients on APT [upper GI endoscopy 25 (27.5%), lower GI endoscopy 66 (72.5%)]. Contrary to the clinical guidelines, aspirin was discontinued in 25 of the 77 patients previously prescribed the drug (32.5%) but this modification was patient's own decision in 11 cases. Most of the apparent deviations in the management of clopidogrel and dual antiplatelet therapy (DAPT) were not true non-adherence cases. The Primary Care physician modified an APT prescribed by another physician in 8 of 9 cases (88.9%), always in cases with aspirin. No relationship was found between the endoscopic procedure's predicted risk of bleeding or the patient's thrombotic risk and modification of therapy. DISCUSSION: In many patients, the peri-procedural management of APT goes against current guidelines, but some of these inconsistencies cannot be considered true deviations from practice. Identified areas for improvement are increasing patient awareness about APT, disseminating the guidelines in Primary Care, and underscoring the significance of thrombotic risk related to APT withdrawal.

[Antipneumococcal vaccination in Catalonian adults: Vaccine coverages and adequacy to distinct guideline recommendations]. / Vacunación antineumocócica en adultos de Cataluña: coberturas y grado de adecuación a distintas guías de recomendaciones.

OBJECTIVES: To know antipneumococcal vaccination coverages among Catalonian adults and evaluate the adequacy of vaccine use according to 3 distinct current vaccination guidelines. DESIGN: Population-based cross-sectional study. SETTING: Primary Health Care. Catalonia, Spain. PARTICIPANTS: A total of 2,033,465 individuals≥50 years-old registered in the Catalonian Health Institute. MAIN MEASUREMENTS: Vaccination status for the 23-valent pneumococcal polysaccharide vaccine (PPV23) and/or the 13-valent pneumococcal conjugate vaccine (PCV13) was revised at 1/01/2015. Adequacy of vaccination status was determined according to 3 distinct vaccination recommendation guidelines: Spanish Ministry of Health (basically coinciding with Catalonian Health Institute's recommendations), Spanish Society of Family Physicians (semFYC) and Centers for Disease Control and Prevention (CDC). RESULTS: Overall, 789,098 (38.8%) persons had received PPV23 and 5,031 (0.2%) had received PCV13. PPV23 coverage largely increased with increasing age (4.8% in 50-59 years, 35.5% in 60-69 years, 71.9% in 70-79 years and 79.5% in≥80 years; P<.001), whereas PCV13 coverage was very small in all age groups. Considering the 3 analysed vaccine guidelines a 46.1% of the overall study population were adequacy vaccinated according to Spanish Ministry's recommendations, 19.3% according to semFYC's recommendations and 4.6% according to CDC's recommendations. CONCLUSION: PPV23 coverage among Catalonian adults may be considered as intermediate, but PCV13 coverage is very small. The institutional recommendations (Spanish Ministry) are more followed than corporative (semFYC) or less local (CDC) recommendations in clinical practice.

Effect of the inadequacy of antibiotic therapy in the Emergency Department on hospital stays. / Efecto de la inadecuación de la antibioterapia en Urgencias sobre la eficiencia en la hospitalización.

INTRODUCTION: The main objective of the study was to determine the frequency of patients receiving inappropriate empiric antibiotic therapy and to assess the impact in terms of increase length of hospital stay, 30-day re-admissions, and 30-day mortality. METHODS: An observational retrospective cohort study was conducted over a one-month period that included all patients hospitalised from an Emergency Department (ED) due to infection. Demographic variables, comorbidity, multi-resistance risk factors, site of infection, microbiological findings, and antibiotic prescribed in ED were collected. Outcomes were length of hospital stay, 30-day re-admissions, and 30-day mortality. RESULTS: A total of 376 patients were included, with a mean age of 71.1 (SD 21) years. The most frequent causes were respiratory (45.7%) and urine (23.9%) infections. The number of patients with length of stay over the median (≥9 days) was 165 (46.1%), with re-admissions 74 (19.7%), and mortality at 30 days 44 (11.7%). There was inappropriate antibiotic treatment in 42 (11.2%) cases. After adjusting for demographic data, comorbidity, risk factors for multidrug resistant organism, presence of sepsis criteria in ED, and site of infection, inappropriate treatment was associated with an extended length of hospital stay (OR 2.22; 95% CI; 1.07-4.60; P=.032), but did not to an increase in mortality (P=.271) or re-admission (P=.784) at 30 days. CONCLUSION: The inappropriate empirical antibiotic therapy in patients admitted from the ED leads to an extended hospital stay, but did not increase mortality or readmission.

[Acceptability and quality of abdominal ultrasound studies requested by medical professionals]. / Adecuación y calidad de las ecografías abdominales solicitadas por los profesionales de medicina.

OBJECTIVE: To evaluate the acceptability/quality of abdominal ultrasound studies requested by primary care physicians in Barcelona; to develop ultrasound guidelines and assess their impact on acceptability. DESIGN: 2-phase study, one retrospective, descriptive phase evaluating the acceptability/quality of requests (pre-intervention phase) and another to assess the impact of guidelines on acceptability/quality (post-intervention phase). SUBJECTS: Requests for ultrasound studies from January-June 2010 from 10 primary care centers and the same number of requests from the same centers after the intervention. VARIABLES: Pre-intervention phase: reason for consultation and request; presence of diagnostic orientation; results of ultrasound; acceptability/quality of the request. INTERVENTION: design guidelines using the nominal group technique, dissemination of guidelines in the same centers. Post-intervention phase: three months after dissemination analyze the same number of requests assessing the same variables included in the pre-intervention phase. RESULTS: Pre-intervention phase: 1,063 requests, 52.4% women, mean age 52±16years (range 11-94). Post-intervention phase: 1,060 requests, 57.6% women, mean age 54±17years (range 6-91). Main reasons for requests: abdominal pain/discomfort 38.3% (pre-intervention) and 43.1% (post-intervention). Diagnostic orientation in 14.5% (pre-intervention) and 40.8% (post-intervention). Normal ultrasound results in 46.0% (pre-intervention) and 42.3% (post-intervention). Good quality of requests in 42.7% (pre-intervention) and 46.5% (post-intervention). Acceptability of ultrasound: 70.5% (pre-intervention) and 94.1% (post-intervention). The better the quality of the request, the better the acceptability of the studies and the greater the number of pathological conditions identified. CONCLUSIONS: Guidelines for ultrasound improve the quality of requests, diagnostic orientation and acceptability of the studies.

[Suitability of strontium ranelate in a health care management area after drug surveillance alerts]. / Adecuación de ranelato de estroncio tras alertas de farmacovigilancia en un área de gestión sanitaria.

OBJECTIVE: To analyse the impact of a strategy on the suitability of strontium ranelate, and its level of acceptance, after issuing recommendations based on drug surveillance alerts issued by the Spanish Medicines and Medical Devices Agency. DESIGN: A prospective interventional study conducted from April 2012 to November 2014. SETTING: South Seville Health Management Area. PARTICIPANTS: Patients currently prescribed with strontium ranelate. INTERVENTIONS: The study consisted of four phases linked to the issue of drug surveillance alerts on strontium ranelate by the Spanish Medicines and Medical Devices Agency, listed by patients and suitability recommendations. MAIN MEASUREMENTS: Suitability of strontium ranelate treatment and the level of acceptance by physicians. RESULTS: There was a reduction of 87.9% in prescriptions from the beginning of the study, with 182 patients included, until the review of the suitability of the drug began. The prescribing of strontium ranelate was unsuitable in 16 out of the 22 patients remaining; 11 of which were due not meeting the treatment criteria, 3 for not having had previous treatments with other drugs for the prevention of fractures, and 2 due to contraindications. The level of acceptance of the recommendations was 87.5%, leading to the stopping of strontium ranelate in 10 patients, and the changing to alendronate or alendronate/cholecalciferol in another four patients. CONCLUSIONS: The number of patients prescribed strontium ranelate has decreased considerably. The interventions directed at reviewing the suitability of this treatment, based on the drug surveillance alerts, have been effective.

[The adapting of a care plan after Kennedy terminal ulcer diagnosis]. / Adecuación del plan de cuidados ante el diagnóstico de úlcera terminal de Kennedy.

A 69 year old man was admitted to the Intensive Care Unit (ICU) from the Emergency Department due to severe respiratory failure. Due to unsuccessful non-invasive mechanical ventilation, endotracheal intubation was performed. A category I ulcer in coccyx was detected 48h after admission. Eight hours later, a double erythema (the second one darker than the first one) with displacement between 30-45° over the bony prominence suggested there was a deep tissue injury. The lesion progressed rapidly during the next 24h. The shape and the rapid evolution of the injury lead us to diagnose a Kennedy terminal ulcer (KTU). At 72h after the admission, and once the causes of acute decompensation were ruled out, limitation of life-sustaining treatment was decided. An individualised plan of care was drawn up with the aim of identifying problems in a patient with KTU evolving from a critical to a terminal situation. Our overall objectives (NOC) were to adapt the care plan based on a realistic approach. Nursing interventions (NIC) included actions such as pain management, conservative treatment of the injury, agony care and support to help the family to make decisions. CONCLUSION: The diagnosis of KTU helped the health care team in the decision-making process when they considered limiting the life support, as well as in the adapting of the care plan to the actual situation.

Routine abdominal X-rays in the emergency department: a thing of the past?

The large number of abdominal X-ray examinations done in the emergency department is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most of these examinations have normal or nonspecific findings, bringing into question the appropriateness of these examinations. Abdominal X-ray examinations are usually considered a routine procedure or even a "defensive" screening tool, whose real usefulness is unknown. For more than 30 years, the scientific literature has been recommending a reduction in both the number of examinations and the number of projections obtained in each examination to reduce the dose of radiation, unnecessary inconvenience for patients, and costs. Radiologists and clinicians need to know the important limitations of abdominal X-rays in the diagnostic management of acute abdomen and restrict the use of this technique accordingly. This requires the correct clinical selection of patients that can benefit from this examination, which would allow better use of alternative techniques with better diagnostic yield, such as ultrasonography or computed tomography.

Sex-biased inbreeding effects on reproductive success and home range size of the critically endangered black rhinoceros.

A central premise of conservation biology is that small populations suffer reduced viability through loss of genetic diversity and inbreeding. However, there is little evidence that variation in inbreeding impacts individual reproductive success within remnant populations of threatened taxa, largely due to problems associated with obtaining comprehensive pedigree information to estimate inbreeding. In the critically endangered black rhinoceros, a species that experienced severe demographic reductions, we used model selection to identify factors associated with variation in reproductive success (number of offspring). Factors examined as predictors of reproductive success were age, home range size, number of nearby mates, reserve location, and multilocus heterozygosity (a proxy for inbreeding). Multilocus heterozygosity predicted male reproductive success (p< 0.001, explained deviance >58%) and correlated with male home range size (p < 0.01, r(2) > 44%). Such effects were not apparent in females, where reproductive success was determined by age (p < 0.01, explained deviance 34%) as females raise calves alone and choose between, rather than compete for, mates. This first report of a 3-way association between an individual male's heterozygosity, reproductive output, and territory size in a large vertebrate is consistent with an asymmetry in the level of intrasexual competition and highlights the relevance of sex-biased inbreeding for the management of many conservation-priority species. Our results contrast with the idea that wild populations of threatened taxa may possess some inherent difference from most nonthreatened populations that necessitates the use of detailed pedigrees to study inbreeding effects. Despite substantial variance in male reproductive success, the increased fitness of more heterozygous males limits the loss of heterozygosity. Understanding how individual differences in genetic diversity mediate the outcome of intrasexual competition will be essential for effective management, particularly in enclosed populations, where individuals have restricted choice about home range location and where the reproductive impact of translocated animals will depend upon the background distribution in individual heterozygosity.

Conservation success as a function of good alignment of social and ecological structures and processes.

How to create and adjust governing institutions so that they align (fit) with complex ecosystem processes and structures across scales is an issue of increasing concern in conservation. It is argued that lack of such social-ecological fit makes governance and conservation difficult, yet progress in explicitly defining and rigorously testing what constitutes a good fit has been limited. We used a novel modeling approach and data from case studies of fishery and forest conservation to empirically test presumed relationships between conservation outcomes and certain patterns of alignment of social-ecological interdependences. Our approach made it possible to analyze conservation outcome on a systems level while also providing information on how individual actors are positioned in the complex web of social-ecological interdependencies. We found that when actors who shared resources were also socially linked, conservation at the level of the whole social-ecological system was positively affected. When the scales at which individual actors used resources and the scale at which ecological resources were interconnected to other ecological resources were aligned through tightened feedback loops, conservation outcome was better than when they were not aligned. The analysis of individual actors' positions in the web of social-ecological interdependencies was helpful in understanding why a system has a certain level of social-ecological fit. Results of analysis of positions showed that different actors contributed in very different ways to achieve a certain fit and revealed some underlying difference between the actors, for example in terms of actors' varying rights to access and use different ecological resources.

Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report.

Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.

Clinical guideline on adequacy and prescription of peritoneal dialysis.

In recent years, the meaning of adequacy in peritoneal dialysis has changed. We have witnessed a transition from an exclusive achievement of specific objectives -namely solute clearances and ultrafiltration- to a more holistic approach more focused to on the quality of life of these patients. The purpose of this document is to provide recommendations, updated and oriented to social and health environment, for the adequacy and prescription of peritoneal dialysis. The document has been divided into three main sections: adequacy, residual kidney function and prescription of continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. Recently, a guide on the same topic has been published by a Committee of Experts of the International Society of Peritoneal Dialysis (ISPD 2020). In consideration of the contributions of the group of experts and the quasi-simultaneity of the two projects, references are made to this guide in the relevant sections. We have used a systematic methodology (GRADE), which specifies the level of evidence and the strength of the proposed suggestions and recommendations, facilitating future updates of the document.

Microbiological etiology and current resistance patterns in acute calculous cholecystitis.

INTRODUCTION: The current treatment for acute calculous cholecystitis (ACC) is early laparoscopic cholecystectomy, in association with appropriate empiric antibiotic therapy. In our country, the evolution of the prevalence of the germs involved and their resistance patterns have been scarcely described. The aim of the study was to analyze the bacterial etiology and the antibiotic resistance patterns in ACC. METHODS: We conducted a single-center, retrospective, observational study of consecutive patients diagnosed with ACC between 01/2012 and 09/2019. Patients with a concomitant diagnosis of pancreatitis, cholangitis, postoperative cholecystitis, histology of chronic cholecystitis or carcinoma were excluded. Demographic, clinical, therapeutic and microbiological variables were collected, including preoperative blood cultures, bile and peritoneal fluid cultures. RESULTS: A total of 1104 ACC were identified, and samples were taken from 830 patients: bile in 89%, peritoneal fluid and/or blood cultures in 25%. Half of the bile cultures and less than one-third of the blood and/or peritoneum samples were positive. Escherichia coli (36%), Enterococcus spp (25%), Klebsiella spp (21%), Streptococcus spp (17%), Enterobacter spp (14%) and Citrobacter spp (7%) were isolated. Anaerobes were identified in 7% of patients and Candida spp in 1%. Nearly 37% of patients received inadequate empirical antibiotic therapy. Resistance patterns were scrutinized for each bacterial species. The main causes of inappropriateness were extended-spectrum beta-lactamase-producing bacteria (34%) and Enterococcus spp (45%), especially in patients older than 80 years. CONCLUSIONS: Updated knowledge of microbiology and resistance patterns in our setting is essential to readjust empirical antibiotic therapy and ACC treatment protocols.

[Epidemiology of anemia in adults: A population based study]. / Epidemiología de la anemia en adultos: estudio observacional de base poblacional.

OBJECTIVE: To determine the prevalence of anemia and the defining characteristics of the individuals who suffer from it. DESIGN: Population-based descriptive observational study. Variables extracted from the computerized database of primary care medical records. SETTING: This study was conducted in the Metropolitana Nord health region, Barcelona. PARTICIPANTS: Patients with anemia evaluated by hemoglobin, during the year 2019. INCLUSION CRITERIA: older than 14 years, with hemoglobin determinations below the value recommended by the WHO. EXCLUSION CRITERIA: no follow-up by public health. MAIN MEASUREMENTS: Demographic variables, clinical variables (drugs, diagnosis of anemia, complex chronic patient or advanced chronic disease. Resource consumption variables (number of visits to primary care, number of hospital admissions, and number of visits to the emergency room). The variables demographic and clinical variables were evaluated using frequencies and percentages, mean and standard deviation for quantitative variables. The characteristics of the different subgroups were compared with Student's t-test. RESULTS: The prevalence of anemia was 3.78%. Mean age 64.5 years and 60.8% women. 15.8% identified as complex chronic patients. Arterial hypertension present in 51.46%. 50.97 were iron deficiency anemias. They consulted the family doctor 2.25 times on average and the family nurse 1.49. Of the people with analytical criteria for anemia, only 46.57 had a registered diagnosis of anemia. CONCLUSIONS: In the territory studied, an under-reporting of the diagnosis of anemia has been observed. Differences are observed in the characterization by gender and age.

Higher carbohydrate quality index is associated with better adequate micronutrient consumption in Brazilian women.

Introduction: Introduction: inadequate consumption of micronutrients is an emerging public health problem that can compromise health. Objectives: to assess whether the quality of dietary carbohydrates is associated with the consumption of 13 micronutrients in a sample of women monitored by the Brazilian Unified Health System. Methods: this cross-sectional study included 648 women monitored by the Brazilian Unified Health System. The association between quality of dietary carbohydrates and adequacy of consumption of 13 micronutrients was investigated using logistic regression models adjusted for potential confounding variables. Results: the consumption of micronutrients increased as the quality of carbohydrates improved. The micronutrients with the highest prevalence of inadequate intake were vitamin A, magnesium, manganese, and thiamine. After adjustments using logistic regression models, women in the third tertile of the carbohydrate quality index were less likely to have an inadequate consumption of magnesium (odds ratio (OR), 0.29; 95 % confidence interval (CI), 0.14-0.59), manganese (OR, 0.32; 95% CI, 0.21-0.49), and copper (OR, 0.22; 95% CI, 0.12-0.37). Conclusions: intake of a higher quality of dietary carbohydrates is associated with improved adequacy in consumption of most micronutrients in women monitored by the Brazilian Unified Health System, especially magnesium, manganese, and copper, after adjustment using regression models.

Introducción: Introducción: el consumo inadecuado de micronutrientes es un problema de salud pública emergente que puede comprometer la salud. Objetivo: evaluar si la calidad de los carbohidratos de la dieta está asociada con el consumo de 13 micronutrientes en una muestra de mujeres monitoreadas por el Sistema Único de Salud de Brasil. Métodos: este estudio transversal incluyó a 648 mujeres monitoreadas por el Sistema Único de Salud de Brasil. La asociación entre la calidad de los carbohidratos de la dieta y la adecuación del consumo de 13 micronutrientes se investigó mediante modelos de regresión logística ajustados por posibles variables de confusión. Resultados: el consumo de micronutrientes aumentó a medida que mejoraba la calidad de los carbohidratos. Los micronutrientes con mayor prevalencia de ingesta inadecuada fueron: vitamina A, magnesio, manganeso y tiamina. Después de los ajustes mediante modelos de regresión logística, las mujeres del tercer tercil del índice de calidad de carbohidratos tenían menos probabilidades de tener un consumo inadecuado de magnesio (odds ratio (OR): 0,29; intervalo de confianza (IC) del 95 %: 0,14-0,59), manganeso (OR: 0,32 ; IC del 95 %: 0,21 a 0,49) y cobre (OR: 0,22; IC del 95 %: 0,12 a 0,37). Conclusiones: la ingesta de una mayor calidad de carbohidratos en la dieta se asocia con una mejor adecuación en el consumo de la mayoría de los micronutrientes en mujeres monitoreadas por el Sistema Único de Salud de Brasil, especialmente magnesio, manganeso y cobre, después del ajuste mediante modelos de regresión.

Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors.

Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.

Recommendations for end-of-life care by emergency health services. / Recomendaciones de cuidados al final de la vida en los servicios de urgencias.

TEXT: Emergency services' main purpose is to save lives, but that worthy mission cannot always be accomplished. When caring for patients toward the end of life, we have an ethical obligation to talk with them and their relatives to obtain consensus on treatment and possibly limit it or adjust management in accordance with the patient's condition. Emergency department protocols are necessary for optimizing care to provide the greatest possible comfort and control of symptoms in patients at the end of life to prevent unnecessary suffering and preserve dignity. This article sets out recommendations - including the principles and ethical standards that underlie them - so that emergency services can develop end-of-life care protocols for use in their own settings.

TEXTO: Los servicios de uUrgencias (SU) tienen como objetivo primordial salvar vidas, pero no debemos olvidar que esta misión encomiable no siempre es posible y, cuando se atienden pacientes en la última fase de la vida, existe la obligación ética de dialogar con ellos y sus familiares para conseguir un consenso y limitar o adecuar el manejo clínico de acuerdo a su situación vital. Con este objetivo, los SU deben tener protocolos de cuidados dirigidos a optimizar el confort y control de síntomas de los pacientes en la fase final de la vida, con el fin de evitar sufrimientos innecesarios y preservar su dignidad personal. El presente artículo expone las recomendaciones (con principios y normas específicas) que deben guiar la elaboración de protocolos de atención al final de la vida en urgencias, con el fin de que cada SU pueda elaborar sus propios protocolos.

Inflammation and hemodialysis adequacy: are C-reactive protein levels influenced by the dose of dialysis?

INTRODUCTION: Chronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the "dialysis dose" with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the "dialysis dose" (Kt / V) using ionic dialysance. METHODS: Multicenter cross-sectional study. 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into two groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence. RESULTS: Median CRP was 4.10 mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48 ± 0.308. Kt/V was lower in the patients included in the high inflammation group (p = 0.01). In the multivariate logistic regression, the "high" levels of CRP were directly correlated with the Log INL (p < 0.001) and inversely proportional with serum albumin values (p = 0.014), Kt/V (p = 0.037) and serum iron (p < 0.001). CONCLUSION: The poorer adequacy in terms of dialysis doses, lower Kt / V values, may contribute to a higher degree of inflammation in chronic hemodialysis patients.

Experience in Spain with the first patients in home hemodialysis treated with low-flow dialysate monitors. / Experiencia en España con los primeros pacientes en hemodiálisis domiciliaria tratados con monitores de bajo flujo de líquido de diálisis.

Home hemodialysis (HHD) with low-flow dialysate devices has gained popularity in recent years due to its simple design, portability, and ability to provide greater freedom of movement for our patients. However, there are doubts about the adequacy that this technology offers, since it uses monitors with low-flow bath and lactate. The aim of this study was to demonstrate the clinical benefits of low-flow HHD with the NxStage System One® recently introduced in Spain. We present the results of an observational, retrospective cohort study that included the first patients who started short daily HHD with this device in 12 Spanish centers. We analyzed the evolution of 86 patients at 0, 6 and 12 months, including data related to prescription, and evolution of biochemical parameters related to dialysis dose, anemia, mineral-bone metabolism; evolution of residual renal function, medication usage, and causes of withdrawal during the followup. We were able to demonstrate that this NxStage System One® monitor, in patients with HHD, have provided an adequate dialysis dose, with optimal ultrafiltration rate, with improvement of main biochemical markers of dialysis adequacy. The usage of this technique was associated to a decrease of antihypertensive drugs, phosphate binders and erythropoietin agents, with very good results both patient and technique survival. The simplicity of the technique, together with its good clinical outcomes, should facilitate the growth and utilization of HHD, both in incident and prevalent patients.