Completion of the informed consent in radioguided surgery by the General Surgery and Nuclear Medicine services of a radioguided surgery unit.

OBJECTIVE: To identify the frequency of errors in informed consent documents in radioguided surgery in a third level hospital and to detect possible causes or factors associated with a greater risk of error. MATERIAL AND METHODS: Informed consent forms of a total of 369 radioguided surgery interventions, completed by the Nuclear Medicine and General Surgery services, were analyzed, and the degree of completion of the forms and its correlation with the physicians responsible, type of pathology, intervention, and waiting time were compared with the completion of consent by another specialty. RESULTS: Errors were identified in 22 consent forms from Nuclear Medicine and 71 from General Surgery. The most common error was the absence of identification of the physician responsible (17 in Nuclear Medicine, 51 in General Surgery), and the second most common was the absence of a document (2 in Nuclear Medicine, 20 in General Surgery). There were significant differences in the errors made depending on the doctor in charge, with no significant correlation with the other variables. CONCLUSIONS: The physicians responsible were the main factor associated with a greater risk of error in the completion of informed consent forms. Further studies are needed to analyze the causal factors and possible interventions to minimize errors.

Epidemiology of blood transfusion in the Spanish Critical Care Units: «Transfusion Day¼.

OBJECTIVE: To describe the transfusion practice in the ICUs in Spain, according to national and international recommendations (guidelines). DESIGN: Prospective, cross-sectional, multi-centre study. SCOPE: Data collection was carried out by means of a questionnaire sent electronically to the Heads of Service of 111 ICUs in Spain. PARTICIPANTS: 1,448 patients were included, aged 61.8 (SD 15.7) years, 66.2% male, with an SOFA of 4.7 ±â€¯3.8 and average stay of 10.62 ±â€¯17.49 days. VARIABLES: Demographic and clinical variables of the patients were collected, as well as variables related to the transfusion act. RESULTS: Of the 1,448 patients, 9.9% received al least one transfusion of any blood product, 3.7% fresh plasma, 3.9% platelets and 8.9% red blood cell concentrate, mainly by analytical criteria (36.2%). Hemoglobin had a mean of 7.8 g/dL (95% CI: 6-9-8.5) and 9.8 g/dL (95% CI: 8.5-11.2) before and after the transfusion, respectively, p < 0.001. The transfusion units had a mean of 2.5 ±â€¯2.4 per patient. The most commonly used blood product was red blood cell concentrate (CH) (90.2%). Patients admitted for surgery had a higher transfusion rate (14.4%) than those admitted for medical pathology (8.9%) (p = 0.006). 5.4% (7/129) of patients who received CH died compared to 2.4% (31/1302) who did not (p = 0.04). Mortality of transfused patients was higher. The transfusion rate in most of hospitals was 5% to 20%, with 18 hospitals (16.21%) having transfusion rates between 20% and 50%. Hospitals with PBM programs and mass transfusion programs had a lower transfusion rate, although not statistically significant. CONCLUSIONS: In this multicenter cross-sectional study, a transfusion prevalence of 9.9% was observed in Spanish Critical Care Units. The most frequent blood product transfused was red blood cells and the main reasons for transfusion were acute anemia with hemodynamic impact and analytical criteria. Mortality of transfused patients was higher.

Analysis of voice in patients with untreated active acromegaly.

BACKGROUND: Voice changes are common clinical findings of acromegaly, although scanty data are available so far. OBJECTIVE: To analyze features and quantify changes of voice in patients with untreated active acromegaly. DESIGN AND METHODS: This was a pilot case-control study. Voice was analyzed using the Multi Dimensional Voice Program software, which generates 33 parameters related to fundamental frequency (F0), micro-perturbation of F0 and amplitude, noise, tremor, voice breaks and irregularities, and diplophony. PATIENTS: Thirteen consecutive patients (8 women, 5 men, mean age 48+/-9 yr) with active acromegaly, at first diagnosis, and 13 sex- and age-matched normal subjects (controls). RESULTS: Patients with untreated active acromegaly had mean values of parameters related to F0 significantly lower than those of controls, although mostly remaining in the normal range. Most acromegalic patients had micro-perturbation of F0, as indicated by higher mean of absolute or percentage jitter values than those of controls; micro-perturbation of amplitude was a common feature of voice in most acromegalic men. Noise-related parameters were also affected by acromegaly, being higher in male acromegalic patients than in controls and acromegalic women. On the contrary, parameters related to tremors, voice breaks, voice irregularities and diplophony did not differ in acromegalic patients and controls. CONCLUSIONS: Patients with untreated active acromegaly had low-pitched voice characterized by lowering F0 and increased values related to noise, micro perturbation of frequency, and amplitude.

Results of the oral egg-challenge test performed on two different groups of children. One group with a history, suggestive of allergic reaction with egg intake and the other group sensitised to hen's egg without previous egg intake.

INTRODUCTION: Egg allergy is an adverse immune-system reaction of an IgE-mediated type, which can happen in children after egg intake and several times after their first egg intake. OBJECTIVES: Compare the results of the oral egg-challenge test in two groups of egg-sensitised children, with and without prior intake. PATIENTS AND METHODS: Retrospective study of two egg-sensitised groups (72 subjects). Group 1: 22 children without prior egg-intake. Group 2: 50 children with a clinical history of adverse reactions after egg intake. Skin prick tests, egg-white specific IgE (sIgE) and yolk specific IgE, were performed on all children. The oral egg-challenge tests were performed after a period of egg-avoidance diet and when egg-white specific IgE levels were lower than 1.5K U/L. RESULTS: 31.8% of the children in Group 1 did not tolerate egg-intake whereas 38% of the children in Group 2 did not tolerate egg-intake. Egg-avoidance periods lasted 19.5 and 18 months, respectively. Egg-white specific IgE levels went down in both groups after an egg-avoidance diet. No statistically significant differences were found between the groups and the positivity of oral egg-challenge test. CONCLUSIONS: No statistically significant differences were found in the behaviour of the two groups studied. Given the high risk of adverse reactions, it was recommended that any egg-introduction tests were to be performed in a hospital environment on the children who were sensitised to hen's egg (including children without prior egg intake).

Epidemiology of blood transfusion in the Spanish Critical Care Units: «Transfusion Day¼. / Epidemiología de la transfusión sanguínea en los Servicios de Medicina Intensiva en España: «Transfusion Day¼.

OBJECTIVE: To describe the transfusion practice in the ICUs in Spain, according to national and international recommendations (guidelines). DESIGN: Prospective, cross-sectional, multi-centre study. SCOPE: Data collection was carried out by means of a questionnaire sent electronically to the Heads of Service of 111 ICUs in Spain. PARTICIPANTS: 1,448 patients were included, aged 61.8 (SD 15.7) years, 66.2% male, with an SOFA of 4.7±3.8 and average stay of 10.62±17.49 days. VARIABLES: Demographic and clinical variables of the patients were collected, as well as variables related to the transfusion act. RESULTS: Of the 1,448 patients, 9.9% received al least one transfusion of any blood product, 3.7% fresh plasma, 3.9% platelets and 8.9% red blood cell concentrate, mainly by analytical criteria (36.2%). Hemoglobin had a mean of 7.8g/dL (95% CI: 6-9-8.5) and 9.8g/dL (95% CI: 8.5-11.2) before and after the transfusion, respectively, p<0.001. The transfusion units had a mean of 2.5±2.4 per patient. The most commonly used blood product was red blood cell concentrate (90.2%). Patients admitted for surgery had a higher transfusion rate (14.4%) than those admitted for medical pathology (8.9%) (p=0.006). 5.4% (7/129) of patients who received red blood cell concentrate died compared to 2.4% (31/1302) who did not (p=0.04). Mortality of transfused patients was higher. The transfusion rate in most of hospitals was 5% to 20%, with 18 hospitals (16.21%) having transfusion rates between 20% and 50%. Hospitals with PBM programs and mass transfusion programs had a lower transfusion rate, although not statistically significant. CONCLUSIONS: In this multicenter cross-sectional study, a transfusion prevalence of 9.9% was observed in Spanish critical care units. The most frequent blood product transfused was red blood cells and the main reasons for transfusion were acute anemia with hemodynamic impact and analytical criteria. Mortality of transfused patients was higher.

Transfusions in the Emergency department: More than a blood transfusion. / Transfusión en Urgencias: algo más que una transfusión de sangre.

Increasing haemoglobin and haematocrit levels with blood transfusions has been the gold standard for treating severe anaemia; however, the indication for transfusing concentrated red blood cells is based merely on a few laboratory markers, such as haemoglobin and haematocrit levels, rather than based on the symptoms according to clinical practice guidelines, the implementation of legal regulations and the consensus achieved by the hospitals' transfusion committees. The aim of this multicentre study was to reassess the suitability of the indication for transfusing concentrated red blood cells and the volumes transfused in emergency departments. We established an observational, multicentre, cross-sectional design with 2 participating centres: the La Paz University Hospital and the Hospital of Salamanca. In total, we obtained data from 381 patients, 220 (57.74%) of whom were men with an average age of 71.4±14.0 years and 161 (42.26%) of whom were women with an average age of 75.3±15.3 years (P<.001). The most prevalent underlying diseases in the patients who underwent transfusions were heart disease, which included haemorrhaging due to antiplatelet or anticoagulant therapy (57.7%), haemato-oncologic (15.3%) diseases and neurological disease. Only 54.9% (209/381) of the prescriptions for transfusion were considered appropriate, with significant differences according to the indication.

Investigating self-care in a sample of patients with decompensated heart failure: A cross-sectional study. / Investigando el autocuidado en una muestra de pacientes con insuficiencia cardiaca descompensada: un estudio transversal.

BACKGROUND: There is scarce evidence relating to self-care of heart failure (HF) in Spain. In particular, there is a need to establish patients' level of understanding of HF, as well as their ability to recognise signs and symptoms of decompensation. PATIENTS AND METHODS: Cross-sectional study to determine the level of self-care in a population of Spanish patients admitted to hospital with a primary diagnosis of decompensated HF. A convenience sample of 108 patients (50 women and 58 men) aged 83±8 were recruited to participate in this study. RESULTS: The Self-Care of Heart Failure Index version 6.2 was used to quantify self-care in our sample. Mean and standard deviation from the Self-Care of Heart Failure Index self-care maintenance subscale were: a) "exercise for 30 minutes", 1±1; b) "forget to take one of your medicines", 2±2; c) "ask for low-salt items when eating out or visiting others", 2±1. A percentage of 67.6 had experienced shortness of breath or ankle swelling in the past month. However, the vast majority of our patients were unlikely to independently implement a remedy: a) reduce salt, 2±1; b) reduce fluid intake, 1±1; c) take an extra diuretic, 1±1. Over 50% of our sample felt confident or very confident at following professional advice (3±1), keeping themselves free of symptoms (3±1), recognizing changes in their condition (3±1) and evaluating the significance of such changes (3±1). CONCLUSIONS: HF patients have a significantly low level of self-care when compared with HF patients from other countries, especially when it comes to managing their condition. Self-care promotion should be a priority for all healthcare professionals involved in the care and management of HF patients.

[Perception of the professional nursing environment in Primary Care in the Valencian Community, in departments with public and private management]. / Percepción del entorno de práctica enfermera de Atención Primaria de la Comunidad Valenciana, en departamentos con gestión pública y privada.

BACKGROUND: Nursing practice environments (NPE) improve the quality of care, satisfaction and heath results; there are no studies that compare the Primary Health Care (PHC) environments according to their management model. Our aim is to estimate and compare the perception of the quality of the NPE in the PHC in Health Departments (HD) of the Valencian Community (Spain) with management model public or indirect-private (Administrative concession). METHOD: Transversal study on PHC nurses from three HD, one with direct public management and two with indirect-private management. The Practice Environment Scale-Nursing Work Index questionnaire, validated in Spain, was administered. Sociodemographic and professional variables were recorded. Variables related to test score were analyzed by multiple linear regression. RESULTS: Two hundred and sixty-nine answers (80.3%). All HD perceived NPE quality in a positive way, both globally and for the different dimensions (except D4). Indirect private management model HD obtained higher global scores, the same tendency was observed for D1 and D2, and the opposite for D4. Global score was related to age, professional experience, being a coordinator and management model; only the age of the nurses and being a coordinator showed a significant relationship with the score in the multivariate regression model. CONCLUSIONS: The NPE of the PHC of the Valencian Community are of good quality, without significant differences according to different management models of the HD. Being a coordinator and, particularly, the age of the nurses are variables that are independently related to the global score obtained.

Fiberoptic endoscopic evaluation of swallowing (FEES): proposal for informed consent.

Fiberoptic endoscopic evaluation of swallowing (FEES) is now a first choice method for studying swallowing disorders on account of the various advantages it offers: easy to use, very well tolerated, allows bedside examination and is economic. Nevertheless, this diagnostic procedure is not without risks, the most probable consequences of which include discomfort, gagging and/or vomiting, vasovagal syncope, epistaxis, mucosal perforation, adverse reactions to topical anaesthetics and laryngospasm. The risks involved with FEES stress the importance of informing the patient of these; this is an important aspect in medicine that necessarily and immediately implies receiving the patient's so-called "informed consent". Informed consent should be obtained not only by means of specific printed forms but also after the patient has had an interview with the physician who will be performing the procedure and who will offer information according to the personal clinical, psychological, cultural and linguistic situation of the patient and in keeping with the type of procedure proposed. In the case of FEES, as with other invasive or non-invasive diagnostic procedures, therefore, routine written and signed consent, together with a patient/physician interview should fulfil what is known as "complete information". In this report, a specific form for informed consent to FEES procedures, is proposed.

Paradoxical vocal cord dysfunction: clinical experience and personal considerations.

Paradoxical vocal cord dysfunction is a nosographic entity that remains to be fully elucidated as far as concerns criteria required for diagnosis and underlying aetiopathogenesis. The disorder manifests with repeated episodes of acute dyspnoea associated with a series of symptoms that may include hoarseness, globus, chest pain and "shortness of breath". A retrospective analysis of cases with acute dyspnoea referred to our Department between June 2004 and June 2005 revealed 3 patients with paradoxical vocal cord dysfunction. In 2 of these 3 cases, concomitant psychiatric morbidity was observed and the third also presented gastro-oesophageal reflux. In one patient, the episodes of dyspnoea were triggered by inspiration of irritating substances. Diagnosis of the condition requires a high level of suspicion, which is confirmed by a laryngoscopic investigation that demonstrates hyperadduction of the true vocal cords and a reduction of at least 50% in the breathing space. From a therapeutic point of view, patients with paradoxical vocal cord dysfunction require, in our opinion, a multidisciplinary approach; in fact, only a team comprising otorhinolaryngologists, phoniatricians, pulmonologists, neurologists, allergologists, psychotherapists and speech therapists is capable of defining the appropriate treatment according to the clinical and psychological characteristics of each individual patient. Our results with speech therapy, focused on respiratory and speech retraining, are reported.

Survey on graduate education in the Confederación Americana de Urología: Opinions and reality. / Encuesta sobre la formación de postgrado en la Confederación Americana de Urología: opiniones y realidades.

OBJECTIVE: Quality graduate medical training is a concern of Confederación Americana de Urología (CAU), the third largest urological society worldwide. It is important to analyse the diversity in the state training programmes and the feasibility and implications of conducting a common CAU programme. MATERIAL AND METHODS: A 20-item questionnaire was distributed to the directors of national societies who are members of the CAU concerning the graduate urological training in their institutions. RESULTS: A total of 28 presidents and expresidents representing 21 countries responded, the total number of independent states that constitute the confederation. In this setting, 664 residents start their training programme every year, in an area that treats 645.4 million inhabitants, with an active professional force of 16,752 specialists. We present data on the realities of the training (length of the programme, core curriculum) and occupation (job access, possible flow between countries) and on how accreditation and re-certification of specialists in these countries are conducted. We also present the opinions on the feasibility of a joint CAU degree, as well as a number of its implications. CONCLUSIONS: The actual graduate training in the CAU setting is heterogeneous in its programmes and in its accreditation and re-certification methods. There is a strong desire to achieve joint degrees, except in Spain and Portugal. To enable joint certification, there will need to be intervention on numerous aspects and levels, redefining the desire for healthcare coverage in each country and considering the possible flow of specialists.

Left mini-thoracotomy for beating heart bypass grafting: a safe alternative to high-risk intervention for selected grafting of the circumflex artery distribution.

BACKGROUND: Progression of disease and bypass graft attrition results in a population of patients who require repeated coronary interventions. Frequently, these patients have patent internal mammary artery grafts and require isolated intervention to the circumflex distribution. As an alternative to high-risk repeated sternotomy and conventional bypass surgery or catheter-based intervention, the circumflex marginal vessels may be approached by thoracotomy. We reviewed our experience in revascularizing the circumflex distribution with off-pump techniques via left mini-thoracotomy. METHODS AND RESULTS: Thirty-two patients underwent off-pump bypass grafting of the circumflex vessels via thoracotomy from December 1995 to April 2000. Twenty-seven patients presented with circumflex disease after having previous bypass grafting. Five patients, who presented with circumflex disease and either nondiseased or ungraftable disease in their other arteries, were revascularized as a primary procedure. There was no observed mortality. Seven patients (22%) required inotropes on leaving the operating room, and 3 patients (9.4%) received transfusion of packed red blood cells. There was 1 reoperation for bleeding and 1 patient with a postoperative neurological deficit. There were no perioperative myocardial infarctions. The average length of stay was 4.8 days from time of surgery to discharge. CONCLUSIONS: Off-pump grafting via thoracotomy provides a safe and effective alternative approach for patients requiring limited revascularization. Potential cardiac injury and danger to viable grafts from repeated sternotomy is minimized, and manipulation of the diseased ascending aorta is avoided. Morbidity, hospital length of stay, and cost are less than for conventional repeated coronary bypass surgery.

Effect of tyrosine on attention deficit disorder with hyperactivity.

A single-blind study was conducted to evaluate the effect of oral tyrosine on attention deficit disorder (ADD) with hyperactivity in seven outpatient children. Since most biological evidence of ADD supports a norepinephrine or dopamine deficiency, the authors hypothesized that tyrosine, which has been shown to increase catecholamine synthesis, would be beneficial in the treatment of ADD. None of the subjects, however, showed any significant improvement with tyrosine. Implications for the catecholamine deficiency hypothesis and treatment strategies for ADD are discussed.

Borderline disorders of childhood: an overview.

This selected review considers children classified as "borderline" and focuses on two broad categories: Borderline personality disorder/borderline spectrum and schizotypal personality disorder/autism/schizophrenia spectrum classifications. Clinical descriptions, biological correlated, delimitation from other disorders, outcome, family studies, hypothesized etiologies, therapeutic considerations, and response to treatment are presented for each. Data support the subclassification of the heterogeneous groupings of borderline children into at least the two categories, and their differentiation from each other and from other clinical disorders in the population. Overlap across the borderline categories exists for individual children. The nature and shortcomings of relevant studies are described, the need for scientifically based research championed, and a differential approach to directive treatment of borderline children advocated. Further subclassification of borderline disorders should result in more cost-effective diagnosis and treatment.

[Fibromuscular dysplasia with moyamoya phenomenon in a patient with Alport's syndrome. A type IV collagen disorder]. / Displasia fibromuscular con fenómeno moyamoya en paciente con síndrome de Alport. Enfermedad del colágeno tipo IV.

INTRODUCTION: Alport's syndrome is a hereditary progressive nephropathy associated with neurosensorial deafness, secondary to mutations of the genes which codify the a chains of collagen IV. In the literature we have found isolated reports of cases with nervous system involvement. CLINICAL CASE: A 37 year old woman was diagnosed as having Alport's syndrome with terminal secondary chronic renal failure and bilateral neurosensorial deafness. She was assessed following repeated transient ischemic attacks of the left hemisphere over the previous three years. Neurological examination was normal. Magnetic resonance showed an ischemic stroke of the left frontal white matter, and on arteriography there was tubular stenosis of the left extracranial internal carotid artery and proximal occlusion of the homolateral anterior and medial cerebral arteries with a compensatory deep vascular network, compatible with fibromuscular dysplasia and secondary moyamoya phenomenon. CONCLUSIONS: Although the association between fibromuscular dysplasia and Alport's syndrome may be casual, we suggest that there may be a common mechanism of pathogenesis in both syndromes, related to the expression of type IV collagen in the vascular basal membranes.

Increased cyclic guanosine monophosphate production and endothelial nitric oxide synthase level in mononuclear cells from sildenafil citrate-treated patients with erectile dysfunction.

Mononuclear cells express enzymes involved in the NO/cyclic guanosine monophosphate (cGMP) generating system, as well as PDE5. The objective of the study was to determine the effect of sildenafil citrate administration on the level of proteins involved in the NO/cGMP generating system in mononuclear cells from patients with ED. Twenty-one patients with ED (International Index of Erectile Function-Erectile Function Domain (IIEF-EFD) 17.9+/-0.8) were enrolled and 100 mg sildenafil citrate on-demand was administered during 12 weeks. All patients showed cardiovascular risk factors. After sildenafil citrate administration, IIEF-EFD score was improved (26+/-1.2 P<0.05). In the mononuclear cells, the protein level of endothelial NO synthase (eNOS) was higher after sildenafil citrate treatment. It was accompanied by reduction in the circulating plasma levels of both high-sensitive C-reactive protein and soluble intercellular adhesive molecule-1. The protein level of soluble guanylate cyclase and PDE5 did not change in the mononuclear cells after sildenafil citrate treatment. However, in the mononuclear cells exogenous NO induced a higher cGMP production after 12-weeks sildenafil citrate administration. In conclusion, in mononuclear cells from patients with ED sildenafil citrate administration increased the level of eNOS protein and increased cGMP production in response to NO. Moreover, sildenafil citrate administration reduced the plasma circulating levels of two biomarkers associated with inflammation.