Treatment, outcomes and costs of asthma exacerbations in Chilean children: a prospective multicenter observational study.

OBJECTIVE: To describe potential regional variations in therapies for severe asthma exacerbations in Chilean children and estimate the associated health expenditures. METHODS: Observational prospective cohort study in 14 hospitals over a one-year period. Children five years of age or older were eligible for inclusion. Days with oxygen supply and pharmacological treatments received were recorded from the clinical chart. A basic asthma hospitalization basket was defined in order to estimate the average hospitalization cost for a single patient. Six months after discharge, new visits to the Emergency Room (ER), use of systemic corticosteroids and adherence to the controller treatment were evaluated. RESULTS: 396 patients were enrolled. Patients from the public health system and from the north zone received significantly more days of oxygen, systemic corticosteroids and antibiotics. Great heterogeneity in antibiotic use among the participating hospitals was found, from 0 to 92.3% (ICC 0.34, 95% CI 0.16-0.52). The use of aminophylline, magnesium sulfate and ketamine varied from 0 to 36.4% between the different Pediatric Intensive Care Units (ICC 0.353, 95% CI 0.010-0.608). The average cost per inpatient was of $1910 USD. 290 patients (73.2%) completed the follow-up six months after discharge. 76 patients (26.2%) were not receiving any controller treatment and nearly a fourth had new ER visits and use of systemic corticosteroids due to new asthma exacerbations. CONCLUSIONS: Considerable practice variation in asthma exacerbations treatment was found among the participating hospitals, highlighting the poor outcome of many patients after hospital discharge, with an important health cost.

[Analysis of an incident notification system and register in a critical care unit]. / Análisis del registro de un sistema de notificación de incidentes en una unidad de cuidados críticos.

OBJECTIVE: To analyse the incident communicated through a notification system and register in a critical care unit. METHODOLOGY: A cross-sectional descriptive study was conducted by performing an analysis of the records of incidents communicated anonymously and voluntarily from January 2007 to December 2013 in a critical care unit of adult patients with severe trauma. STUDY VARIABLES: incident type and class, professional reports, and suggestions for improvement measures. A descriptive analysis was performed on the variables. RESULTS: Out of a total of 275 incidents reported, 58.5% of them were adverse events. Incident distributed by classes: medication, 33.7%; vascular access-drainage-catheter-sensor, 19.6%; devices-equipment, 13.3%, procedures, 11.5%; airway tract and mechanical ventilation, 10%; nursing care, 4.1%; inter-professional communication, 3%; diagnostic test, 3%; patient identification, 1.1%, and transfusion 0.7%. In the medication group, administrative errors accounted for a total of 62%; in vascular access-drainage-catheter-sensor group, central venous lines, a total of 27%; in devices and equipment group, respirators, a total of 46.9%; in airway self-extubations, a total of 32.1%. As regards to medication errors, 62% were incidents without damage. Incident notification by profession: doctors, 43%, residents, 5.6%, nurses, 51%, and technical assistants, 0.4%. CONCLUSIONS: Adverse events are the most communicated incidents. The events related to medication administration are the most frequent, although most of them were without damage. Nurses and doctors communicate the incidents with the same frequency. In order to highlight the low incident notification despite it being an anonymous and volunteer system, therefore, it is suggested to study measurements to increase the level of communication.

Biomechanical assessment and clinical analysis of different intramedullary nailing systems for oblique fractures.

The aim of this study is to evaluate the fracture union or non-union for a specific patient that presented oblique fractures in tibia and fibula, using a mechanistic-based bone healing model. Normally, this kind of fractures can be treated through an intramedullary nail using two possible configurations that depends on the mechanical stabilisation: static and dynamic. Both cases are simulated under different fracture geometries in order to understand the effect of the mechanical stabilisation on the fracture healing outcome. The results of both simulations are in good agreement with previous clinical experience. From the results, it is demonstrated that the dynamization of the fracture improves healing in comparison with a static or rigid fixation of the fracture. This work shows the versatility and potential of a mechanistic-based bone healing model to predict the final outcome (union, non-union, delayed union) of realistic 3D fractures where even more than one bone is involved.

[Pain assessment of tracheal suctioning on brain injury patients by pain behavioral indicator scale (ESCID)]. / Valoración del dolor en la aspiración de secreciones traqueales en pacientes con traumatismo craneal mediante la Escala de conductas indicadoras de dolor (ESCID).

OBJECTIVE: To assess pain response on patients with moderate to severe head injury before a common nursing procedure: tracheal suctioning. MATERIAL AND METHOD: An observational longitudinal pilot study with consecutive sampling performed from September to December of 2012. Pain was assessed by a pain behavioral indicator scale 5 minutes before, meanwhile and 15 minutes after tracheal suctioning the days 1, 3 and 6 of their intensive care unit (ICU) stay, as well as a non-painful procedure: rubbing with gauze the forearm of the patient. Pseudo-analgesia and hemodynamic variables were also recorded. Descriptive analysis of the variables, inferential statistics with t-student and Anova with SPSS 17.0; statistical tests were considered significant if the critical level observed was less than 5% (P<.05). RESULTS: Pain was assessed on 27 patients. 82% suffered from severe head trauma and 18% moderate. The average pain value during nursing procedure day 1 was 3, 18±2.6, day 3: 2, 59±2 and day 6: 3, 94±2.3. There was a significant increase in mean pain while performing suctioning during the three days of assessment (P<.05); however no significant differences between the average pain value on the three days of the assessment (P>.05) were shown. Data for the painless procedure were significantly different on day 6 (P<.05) CONCLUSION: During tracheal suctioning in patients with head injury in the first 6 days in the ICU, objective mild-moderate pain according to ESCID scale has been detected.

Use of the FLUKA Monte Carlo code for 3D patient-specific dosimetry on PET-CT and SPECT-CT images.

Patient-specific absorbed dose calculation for nuclear medicine therapy is a topic of increasing interest. 3D dosimetry at the voxel level is one of the major improvements for the development of more accurate calculation techniques, as compared to the standard dosimetry at the organ level. This study aims to use the FLUKA Monte Carlo code to perform patient-specific 3D dosimetry through direct Monte Carlo simulation on PET-CT and SPECT-CT images. To this aim, dedicated routines were developed in the FLUKA environment. Two sets of simulations were performed on model and phantom images. Firstly, the correct handling of PET and SPECT images was tested under the assumption of homogeneous water medium by comparing FLUKA results with those obtained with the voxel kernel convolution method and with other Monte Carlo-based tools developed to the same purpose (the EGS-based 3D-RD software and the MCNP5-based MCID). Afterwards, the correct integration of the PET/SPECT and CT information was tested, performing direct simulations on PET/CT images for both homogeneous (water) and non-homogeneous (water with air, lung and bone inserts) phantoms. Comparison was performed with the other Monte Carlo tools performing direct simulation as well. The absorbed dose maps were compared at the voxel level. In the case of homogeneous water, by simulating 10(8) primary particles a 2% average difference with respect to the kernel convolution method was achieved; such difference was lower than the statistical uncertainty affecting the FLUKA results. The agreement with the other tools was within 3­4%, partially ascribable to the differences among the simulation algorithms. Including the CT-based density map, the average difference was always within 4% irrespective of the medium (water, air, bone), except for a maximum 6% value when comparing FLUKA and 3D-RD in air. The results confirmed that the routines were properly developed, opening the way for the use of FLUKA for patient-specific, image-based dosimetry in nuclear medicine.

A free database of radionuclide voxel S values for the dosimetry of nonuniform activity distributions.

The increasing availability of SPECT/CT devices with advanced technology offers the opportunity for the accurate assessment of the radiation dose to the biological target volume during radionuclide therapy. Voxel dosimetry can be performed employing direct Monte Carlo radiation transport simulations, based on both morphological and functional images of the patient. On the other hand, for voxel dosimetry calculations the voxel S value method can be considered an easier approach than patient-specific Monte Carlo simulations, ensuring a good dosimetric accuracy at least for anatomic regions which are characterized by uniform density tissue. However, this approach has been limited because of the lack of tabulated S values for different voxel dimensions and radionuclides. The aim of this work is to provide a free dataset of values which can be used for voxel dosimetry in targeted radionuclide studies. Seven different radionuclides (89Sr, 90Y, 131I, 153Sm, 177Lu, 186Re, 188Re), and 13 different voxel sizes (2.21, 2.33, 2.4, 3, 3.59, 3.9, 4, 4.42, 4.8, 5, 6, 6.8 and 9.28 mm) are considered. Voxel S values are calculated performing simulations of monochromatic photon and electron sources in two different homogeneous tissues (soft tissue and bone) with DOSXYZnrc code, and weighting the contributions on the basis of the radionuclide emission spectra. The outcomes are validated by comparison with Monte Carlo simulations obtained with other codes (PENELOPE and MCNP4c) performing direct simulation of the radionuclide emission spectra. The differences among the different Monte Carlo codes are of the order of a few per cent when considering the source voxel and the bremsstrahlung tail, whereas the highest differences are observed at a distance close to the maximum continuous slowing down approximation range of electrons. These discrepancies would negligibly affect dosimetric assessments. The dataset of voxel S values can be freely downloaded from the website www.medphys.it.

[Incidence of phlebitis due to peripherally inserted venous catheters: impact of a catheter management protocol]. / Incidencia de flebitis secundaria por catéter venoso de acceso periférico e impacto de un protocolo de manejo.

OBJECTIVE: To assess the impact on the incidence of PPIVC by implementing a catheter management protocol and to determine risk factors for PPIVC development in hospitalized patients. METHOD: A total of 3978 episodes of venous catheterization were prospectively included from September 2002 to December 2007. A catheter management protocol was implemented during this period of time. The incidence and variables associated to the occurrence of PPIVC were determined. RESULTS: The incidence of PPIVC from 2002 to 2007 was 4.8%, 4.3%, 3.6%, 2.5%, 1.3% and 1.8% (p<0.001). Perfusion of amiodarone [adjusted OR (AOR) 25.97; 95% CI=7.29-92.55, p=0.0001] and cefotaxime (AOR 2.90; 95% CI=1.29-6.52, p=0.01) and the shift when the catheters were placed (AOR for morning vs. night shift 0.60; 95% CI=0.35-1.02, p=0.063) were independently associated to the development of PPIVC. A history of phlebitis was the only factor independently associated to phlebitis due to peripherally inserted central venous catheters (AOR 3.24; CI at 95% CI= 1.05-9.98, p=0.04). CONCLUSIONS: A catheter management protocol decreases the incidence of PPIVC in hospitalized patients. The risk of PPIVC increases for peripherally inserted central venous catheters when the patients have a history of phlebitis and for peripheral venous catheters when amiodarone or cefotaxime are infused. Catheterization of peripheral veins performed during morning shifts is associated with a lower incidence of PPIVC when compared with night shift catheterizations.

Differences among Monte Carlo codes in the calculations of voxel S values for radionuclide targeted therapy and analysis of their impact on absorbed dose evaluations.

Several updated Monte Carlo (MC) codes are available to perform calculations of voxel S values for radionuclide targeted therapy. The aim of this work is to analyze the differences in the calculations obtained by different MC codes and their impact on absorbed dose evaluations performed by voxel dosimetry. Voxel S values for monoenergetic sources (electrons and photons) and different radionuclides (90Y, 131I, and 188Re) were calculated. Simulations were performed in soft tissue. Three general-purpose MC codes were employed for simulating radiation transport: MCNP4C, EGSnrc, and GEANT4. The data published by the MIRD Committee in Pamphlet No. 17, obtained with the EGS4 MC code, were also included in the comparisons. The impact of the differences (in terms of voxel S values) among the MC codes was also studied by convolution calculations of the absorbed dose in a volume of interest. For uniform activity distribution of a given radionuclide, dose calculations were performed on spherical and elliptical volumes, varying the mass from 1 to 500 g. For simulations with monochromatic sources, differences for self-irradiation voxel S values were mostly confined within 10% for both photons and electrons, but with electron energy less than 500 keV, the voxel S values referred to the first neighbor voxels showed large differences (up to 130%, with respect to EGSnrc) among the updated MC codes. For radionuclide simulations, noticeable differences arose in voxel S values, especially in the bremsstrahlung tails, or when a high contribution from electrons with energy of less than 500 keV is involved. In particular, for 90Y the updated codes showed a remarkable divergence in the bremsstrahlung region (up to about 90% in terms of voxel S values) with respect to the EGS4 code. Further, variations were observed up to about 30%, for small source-target voxel distances, when low-energy electrons cover an important part of the emission spectrum of the radionuclide (in our case, for 131I). For 90Y and 188Re, the differences among the various codes have a negligible impact (within few percents) on convolution calculations of the absorbed dose; thus either one of the MC programs is suitable to produce voxel S values for radionuclide targeted therapy dosimetry. However, if a low-energy beta-emitting radionuclide is considered, these differences can affect also dose depositions at small source-target voxel distances, leading to more conspicuous variations (about 9% for 1311) when calculating the absorbed dose in the volume of interest.

[Social inequities in the use of primary care services: a long way to go]. / Desigualdades sociales en la utilización de servicios de atención primaria: un largo camino por recorrer.

OBJECTIVE: To describe the relation between the main variables related with social inequality and the utilization of primary care services. METHODS: Socio-demographic variables and the number of consultations were collected in a cross-sectional study. RESULTS: 264 subjects were interviewed. 66% of the population belonged to social classes IV and V. There was statistical signification between age and number of visits (p = 0.0014) and between number of visits and monoparental families (p = 0.01). CONCLUSIONS: Most of the attended population belonged to the low and middle socio-economic levels. The relationship between non-structured families and hyper-utilization and the relationship between age and hyper-utilization is confirmed.

[Age and sex distribution of sexually transmitted diseases in Valladolid. A study of 5076 cases]. / Distribución por edad y sexo de las enfermedades de transmisión sexual en Valladolid. Estudio de 5.076 casos.

The age and sex distribution of 5,076 cases of S.T.D. dealt with between 1982 and 1988 at the Dermatological Dispensary of the Territorial Social Welfare Service in Valladolid are studied. The maximum frequency of S.T.D. (24.1% of cases) corresponded to the age group between 21 and 25 years, which was also the period for maximum prevalence of Neisseria gonorrhoeae (26.3%), Gardnerella vaginalis (30.7%), Candida albicans (27.4%) and acuminata condyloma (33.4%). Syphilis (19.9%), Chlamydia trachomatis (27%), Ureaplasma urealyticum (24.6%), Mycoplasma hominis (25.0%), Trichomonas vaginalis (23.0%) and genital herpes had maximum prevalence in the group between 26 and 30 years. Women were affected at younger ages than males. 16.9% of women with some S.T.D. were between 16 and 20 years of age, while only 6.5% of males with S.T.D. were in this age-group (p less than 0.001).

[Histopathologic evaluation of death certificates in Soria in 1985]. / Valoración histopatológica de los boletines de defunción en Soria en 1985.

The aim of this paper is to evaluate the quality of the Death Certificates by means of the Death Statistics Bulletins, in their NEOPLASIC aspect in the year 1985 in the Province of Soria, determining the histopathologic confirmation of the deaths by means of the neoplasic patients' records in the two existing Pathology Services. An overall histologic verification of 80.76% is observed in the cases with an I.C. of +/- 4.79. In the case of BREAST, HEMATOLOGIC, OROPHARYNX, ENDOMETRIUM, ESOPHAGUS, OVARIAN, LARYNX and VULVA tumors, it is 100%. Whereas it is 14.3% in HEPATIC Tumors. Of the total of deaths registered in said year, the percentage of deaths caused by malignant neoplasias is over 26%, more than a fourth of which were Gastric. The preparation of the Death Certificates should be modified so that they can be objectively evaluated epidemiologically without bias or mistakes.