Effectiveness and Safety of Postoperative Hospital at Home for Surgical Patients: A Cohort Study.

OBJECTIVE: To determine the feasibility and effectiveness of a Hospital at Home (HaH) enabled early transfer pathways for surgical patients. BACKGROUND: HaH serves as a safe alternative to traditional hospitalization by providing acute care to patients in their homes through a comprehensive range of hospital-level interventions. To our knowledge, no studies have been published to date reporting a large cohort of early home-transferred patients after surgery through a HaH unit. METHODS: Cohort study enrolling every patient admitted to the HaH unit of a tertiary hospital who underwent any of 6 surgeries with a predefined early transfer pathway and fitting both general and surgery inclusion criteria (clinical and hemodynamic stability, uncomplicated surgery, presence of a caregiver, among others) from November 2021 to May 2023. Protocols were developed for each pathway between surgical services and HaH to deliver the usual postoperative care in the home setting. Discharge was decided according to protocol. An urgent escalation pathway was also established. RESULTS: During the study period, 325 patients were included: 141 were bariatric surgeries, 85 kidney transplants, 45 thoracic surgeries, 37 cystectomies, 10 appendicectomies, and 7 ventral hernia repairs. The overall escalation of care during HaH occurred in 7.3% of patients and 30-day readmissions in 7%. Most adverse events were managed at home and the overall mortality was zero. The total mean length of stay was 8 days (interquartile range 2-14), and patients with HaH were transferred home 3 days (interquartile range 1-6) earlier than the usual pathway; a total of 1551 bed-days were saved. CONCLUSIONS: The implementation of early home transfer pathways for surgical patients through HaH is feasible and effective, with favorable safety outcomes.

The value of admission avoidance: cost-consequence analysis of one-year activity in a consolidated service.

BACKGROUND: Many advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs. The objective is to assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain). METHODS: A retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017-2018, was carried out with a health system perspective. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated. RESULTS: HaH-HA and Controls (n = 441 each) were comparable in terms of age (73 [SD16] vs. 74 [SD16]), gender (male, 57% vs. 59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%); p < 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs. 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p < 0.001). CONCLUSIONS: The study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance. REGISTRATION: ClinicalTrials.gov (26/04/2017; NCT03130283).

Five years of Hospital at Home adoption in Catalonia: impact, challenges, and proposals for quality assurance.

BACKGROUND: Hospital at home (HaH) was increasingly implemented in Catalonia (7.7 M citizens, Spain) achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional program and provide context-independent recommendations for continuous quality improvement of the service. METHODS: A mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. HaH (admission avoidance modality) was compared with a conventional hospitalization group using propensity score matching techniques. We evaluated the 12-month period before the admission, the hospitalization, and use of healthcare resources at 30 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. RESULTS: The adoption of HaH steadily increased from 5,185 episodes/year in 2015 to 8,086 episodes/year in 2019 (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients. Mortality rates were similar between HaH and conventional hospitalization within the episode [76 (0.31%) vs. 112 (0.45%)] and at 30-days after discharge [973(3.94%) vs. 1112(3.24%)]. Likewise, the rates of hospital re-admissions at 30 days after discharge were also similar between groups: 2,00 (8.08%) vs. 1,63 (6.58%)] or ER visits [4,11 (16.62%) vs. 3,97 (16.03%). The 27 hospitals assessed showed high variability in patients' age, multimorbidity, severity of episodes, recurrences, and length of stay of HaH episodes. Recommendations aiming at enhancing service delivery were produced. CONCLUSIONS: Besides confirming safety and value generation of HaH for selected patients, we found that this service is delivered in a case-mix of different scenarios, encouraging hospital-profiled monitoring of the service.

Morphologic Differentiation of the Exotic Parasitoid Eupelmus pulchriceps (Hymenoptera: Eupelmidae) in the Galapagos Archipelago.

The historical and geographical properties of the archipelagos allow a detailed study of species diversification, and phenotypic traits can indicate the extent of such processes. Eupelmus pulchriceps (Cameron, 1904) is an exotic species to the Galapagos archipelago, and generalist parasitoid that attacks a beetle species that consumes the seeds of the invasive shrub Leucaena leucocephala (Lam.) de Wit. Despite extensive sampling, the wasp is recorded only in Santa Cruz and San Cristobal islands of the Galapagos archipelago. Thus, using 112 female wasps, we compare body size, proportion, and allometric differentiations within and between the two islands. There were no body size differences between islands. A PerMANOVA indicates differences between the islands and a single differentiation between two localities of one island. Allometric differences between islands were not the same for all structures. These results are consistent with the greater distance between islands than between localities and suggest a differentiation process. The variables with allometric differentiation are associated with wings and ovipositor, possibly responding to different ecological pressures. It is interesting that this parasitoid, recently arrived at the archipelago, is already showing differentiation. Also, it is essential to monitor the behavior of these wasps in the archipelago, given their potential to access other species affecting the trophic interactions of the local biota.

Crisis adrenal neonatal secundaria a hipoplasia hipofisaria / Neonatal Adrenal Crisis Secondary to Pituitary Hypoplasia

Introducción: La insuficiencia adrenal hipotálamo hipofisaria usualmente se manifiesta secundaria a tumores y, cuando resulta congénita se asocia, con frecuencia, con otras deficiencias hormonales. La crisis adrenal suele presentarse en su debut y puede resultar potencialmente mortal. Objetivo: Examinar el caso de una paciente con insuficiencia adrenal central que debutó con una crisis adrenal congénita. Presentación del caso: Recién nacida a término, padres no consanguíneos, hospitalizada a los 9 días de vida por clínica de una semana con múltiples episodios eméticos y apnea. Ingresó con deshidratación severa, hipotensa y estuporosa. Además, se encontró acidosis metabólica severa, hipoglucemia persistente, hiponatremia e insuficiencia prerrenal. Ante la no mejoría de su estado hemodinámico, a pesar del uso de cristaloides y vasopresores, finalmente mejoró con la administración de dosis altas de hidrocortisona. El diagnóstico de deficiencia de cortisol de origen central se realizó con un test dinámico de insulina y la resonancia magnética nuclear hipofisaria. Conclusiones: La crisis adrenal se debe tener presente como diagnóstico diferencial en episodios agudos con inestabilidad hemodinámica persistente e hipoglucemia de difícil manejo. Adicionalmente, hay que considerar que existen otras causas menos comunes de insuficiencia adrenal en neonatos como la hipoplasia hipofisaria(AU)

Introduction: Hypothalamic-pituitary adrenal insufficiency usually manifests secondary to tumors and, when congenital, is often associated with other hormonal deficiencies. Adrenal crisis usually occurs at its onset and can be life threatening. Objective: To review the case of a patient with central adrenal insufficiency who had an onset with a congenital adrenal crisis. Case presentation: Term newborn, non-consanguineous parents, hospitalized at 9 days of life for a week-long clinical presentation with multiple emetic episodes and apnea. She was admitted with severe dehydration, hypotensive and stuporous. In addition, severe metabolic acidosis, persistent hypoglycemia, hyponatremia and prerenal failure were found. Given the lack of improvement of her hemodynamic status, despite the use of crystalloids and vasopressors, she finally improved with the administration of high doses of hydrocortisone. The diagnosis of cortisol deficiency of central origin was made with a dynamic insulin test and pituitary nuclear magnetic resonance imaging. Conclusions: Adrenal crisis should be kept in mind as a differential diagnosis in acute episodes with persistent hemodynamic instability and difficult-to-manage hypoglycemia. Additionally, other less common causes of adrenal insufficiency in neonates, such as pituitary hypoplasia, should be considered(AU)

Pneumococcal superinfection in COVID-19 patients: A series of 5 cases / Sobreinfección por neumococo en pacientes con COVID-19: una serie de 5 casos

BACKGROUND: In the context of the COVID-19 pandemic the risk of misdiagnosis of other causes of respiratory infection is likely. In this work we aim to describe the clinical characteristics, treatment and outcome of pneumococcal infection in COVID-19 patients. PATIENTS AND METHODS: Every COVID-19 patient presenting with concomitant pneumococcal pneumonia during March 2020 in a tertiary teaching Hospital In Barcelona, Spain. RESULTS: Five patients with PCR confirmed COVID19 or clinical and radiological suspicion were diagnosed of pneumococcal infection. In all cases chest X-ray were abnormal, with unilateral or bilateral infiltrates. Procalcitonin showed to be not sensitive enough to detect pneumococcal infection. Antibiotherapy was promptly started in all five cases with subsequent satisfactory evolution. CONCLUSION: International guidelines do not include the universal screening for bacterial co-infection. Radiological pattern of COVID-19 can be indistinguishable from that of pneumococcus pneumonia and frequency of co-infection is not well stablished, therefore clinicians should be aware of the possible SARS-CoV-2-pneumococcus association to avoid misdiagnosis and delay antibiotic therapy

INTRODUCCIÓN: En el contexto de la pandemia por COVID-19 el riesgo de errores en el diagnóstico de otras causas de infección respiratoria es elevado. En este trabajo describimos las características clínicas, el tratamiento y la evolución de los pacientes con coinfección por COVID-19 y neumococo. PACIENTES Y MÉTODOS: Todos los pacientes con COVID-19 que presentaron neumonía neumocócica durante marzo 2020 en un hospital universitario de Barcelona, España. RESULTADOS: Cinco pacientes con COVID-19 confirmada por PCR o sospecha radiológica fueron diagnosticados de infección por neumococo. En todos los casos la radiografía de tórax era patológica con infiltrado unilateral o bilateral. La procalcitonina demostró no ser suficientemente sensible para detectar la infección neumocócica. La antibioterapia fue iniciada de manera precoz en los 5 casos con evolución satisfactoria. CONCLUSIONES: Las guías internacionales no incluyen el cribado universal para coinfección bacteriana. El patrón radiológico del COVID-19 puede ser indistinguible de la neumonía neumocócica, y la frecuencia de la coinfección no ha sido establecida. Los clínicos deben de ser conscientes de la posible asociación de SARS-CoV-2 y neumococo para evitar errores diagnósticos y retrasos en el tratamiento antibiótico

Predictive factors for inadequate bowel cleansing in colon capsule endoscopy / Factores predictores de limpieza colónica inadecuada en exploraciones con cápsula endoscópica de colon

Background and aims: Achieving adequate bowel cleansing is of utmost importance for the efficiency of colon capsule endoscopy (CCE). However, information about predictive factors is lacking. The aim of this study was to assess the predictive factors of poor bowel cleansing in the CCE setting. Methods: In this observational study, 126 patients who underwent CCE at two tertiary care hospitals were included between June 2017 and January 2020. Participants prepared for bowel cleansing with a 1-day clear liquid diet, a 4-L split-dose polyethylene glycol regimen and boosters with sodium phosphate, sodium amidotrizoate and meglumine amidotrizoate. Domperidone tablets and bisacodyl suppositories were administered when needed. Overall and per-segment bowel cleansing was evaluated using a CCE cleansing score. Simple and multiple logistic regression analysis were carried out to assess poor bowel cleansing and excretion rate predictors. Results: Overall bowel cleansing was optimal in 53 patients (50.5%). Optimal per-segment bowel cleansing was achieved as follows: cecum (86 patients; 74.8%), transverse colon (91 patients; 81.3%), distal colon (81 patients; 75%) and rectum (64 patients; 66.7%). In the univariate analysis, elderly (OR, 1.03; 95% CI (1.01–1.076)) and constipation (OR, 3.82; 95% CI (1.50–9.71)) were associated with poor bowel cleansing. In the logistic regression analysis, constipation (OR, 3.77; 95% CI (1.43–10.0)) was associated with poor bowel cleansing. No variables were significantly associated with the CCE device excretion rate. Conclusion: Our results suggest that constipation is the most powerful predictor of poor bowel cleansing in the CCE setting. Tailored cleansing protocols should be recommended for these patients.(AU)

Antecedentes y objetivos Lograr una limpieza intestinal adecuada es de gran importancia para la eficiencia de la cápsula endoscópica de colon (CEC). Se carece de información sobre factores predictivos. El objetivo fue evaluar los factores predictivos de la limpieza colónica deficiente en pacientes con CEC. Métodos: Ciento veintiséis pacientes fueron sometidos a CEC en dos hospitales de tercer nivel entre junio de 2017 y enero de 2020. La preparación consistió en un día de dieta líquida, y 4 l de polietilenglicol (dosis fraccionada), fosfato sódico, amidotrizoato de sodio y meglumina amidotrizoato. Ocasionalmente se administró domperidona y supositorios de bisacodilo. Se evaluó limpieza total y por segmentos. Se realizó un análisis de regresión logística simple y múltiple para evaluar factores de limpieza deficiente y de excreción de la CEC. Resultados: La limpieza intestinal fue óptima en 53 pacientes (50,5%). Por segmentos fue: ciego y ascendente (86 pacientes; 74,8%), transverso (91 pacientes; 81,3%), distal (81 pacientes; el 75%) y recto (64 pacientes; 66,7%). En la regresión simple, la edad avanzada (OR, 1,03, IC 95% [1,01-1,076]) y el estreñimiento (OR, 3,82; IC 95% [1,50-9,71]) se asociaron con una limpieza deficiente. El estreñimiento (OR, 3,77; IC del 95% [1,43-10,0]) fue el único factor asociado de forma independiente. Ninguna variable se asoció a la tasa de excreción de la CEC. Conclusión: Nuestros resultados sugieren que el estreñimiento es el factor más potente de la limpieza deficiente colónica en el estudio endoscópico con CEC. Protocolos de limpieza adaptados se deben recomendar en estos pacientes.(AU)

Therapeutic impact of colon capsule endoscopy with PillCam(TM) COLON 2 after incomplete standard colonoscopy: a Spanish multicenter study

Introduction: Colon capsule endoscopy (CCE) is an alternative approach for the examination of the colon in patients who refuse colonoscopy or after incomplete colonoscopy (IC). We conducted a study to determine the frequency of complete colonoscopy after IC, the diagnostic yield of CCE, the therapeutic impact of lesions found in CCE, the level of colon cleanliness and the safety of the procedure. Methods: We performed a prospective, multicenter study involving ten Spanish hospitals. Consecutive outpatients aged ≥ 18 years with previous IC were invited to participate. The latest version of the CCE device, PillCam(TM) COLON 2 (CCE-2), was administered to all patients according to the protocol. Results: The study population comprised 96 patients. The most frequent cause of IC was the inability to move past a loop using standard maneuvers (75/96 patients, 78%). Complete visualization of the colon was obtained with CCE-2 in 69 patients (71.9%). Of the 27 patients in whom the CCE-2 did not reach the hemorrhoidal plexus, it passed the colonic segment explored with the previous colonoscopy in 20 cases; therefore, it could be inferred that a combined approach (CCE-2 plus colonoscopy) enabled complete visualization of the colonic mucosa in 92.7% of patients. CCE-2 revealed new lesions in 58 patients (60.4%). Polyps were the most frequent finding (41 patients; 42.7% of the total number of patients). In 43 of the 58 patients (44.8% of the total number of patients), the new lesions observed led to modification of therapy, which included a new colonoscopy for polyp resection or surgery in patients with colonic neoplasm. Conclusions: CCE-2 is a suitable diagnostic procedure that can lead to more frequent diagnosis of significant colonic lesions after IC (AU)

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Características de la prescripción de antibióticos en un servicio de urgencias de un hospital de tercer nivel / Antibiotic prescription in the emergency department of a tertiary level hospital

Objetivos: Analizar la prescripción de antibióticos en un servicio de urgencias hospitalario (SUH) mediante la evaluación del tiempo hasta la primera dosis, el ajuste a función renal, la adecuación según resultados microbiológicos y el paso precoz a vía oral. Método: Se identificaron los pacientes que recibieron una primera dosis de antibiótico por vía intravenosa con intención terapéutica en el SUH. Los pacientes fueron seguidos de manera prospectiva mientras duró el tratamiento antibiótico. Resultados: Se incluyeron 98 pacientes. La mediana del tiempo hasta la primera dosis de antibiótico fue de 180 minutos (media 215 min, DE: 127 min) desde la llegada a urgencias y de 120 minutos (media 132 min, DE: 80 min) desde la visita médica. Doce pacientes cumplieron criterios de sepsis grave y 7 de shock séptico, y en ellos la mediana entre la valoración médica y la primera dosis de antibiótico fue de 93 y 60 minutos respectivamente. El ajuste a la función renal fue realizado en el 95% de pacientes, y en el 97% se ajustó el tratamiento a los aislamientos microbiológicos. El paso a vía oral fue realizado en el 98% de los casos elegibles, con un retraso medio de 1,7 días. Conclusiones: El tiempo hasta la administración de la primera dosis de antibiótico en el SUH es mayor a lo recomendado incluso en los pacientes con sepsis grave y shock séptico

Objectives: To analyze the prescription of antibiotics in a hospital emergency department (ED) by assessing time elapsed until the first antibiotic dose, adjustment of renal function, adjustment according to the findings for microbiology, and early switch to oral route of administration. Methods: Patients were included consecutively on receiving a first intravenous dose of an antibiotic in the ED. The patients were followed prospectively while they were on antibiotic treatment. Results: We included 98 patients. The median time until the first dose was 180 minutes from the time of arrival in the department; the mean (SD) time was 215 (127) minutes. The median time from first medical evaluation until the first dose was 120 minutes; the mean time was 132 (80) minutes. Twelve of the 98 patients had severe sepsis and 7 were in septic shock. In these patients the median time between physician evaluation and first antibiotic dose was 93 minutes (severe sepsis) and 60 minutes (septic shock). In 95% of the patients, the dosage was adjusted based on renal function; in 97% treatment was adjusted based on results of microbiology. Ninety-eight percent of patients were switched to oral antibiotics after a mean of 1.7 days. Conclusions: Time elapsed until the first antibiotic dose administered in the ED is longer than recommended even for patients with severe sepsis or in septic shock

Sensibilidad a la recompensa y al castigo, personalidad, impulsividad y aprendizaje: un estudio en un contexto de violencia de pareja / Sensitivity to reward and punishment, personality, impulsivity, and learning: A study in a context of intimate partner violence

El objetivo de la presente investigación es estudiar los patrones de sensibilidad a la recompensa y al castigo en una tarea de aprendizaje y su relación con distintas dimensiones de personalidad en una muestra de 81 mujeres víctimas de violencia de pareja. Se evalúa la sensibilidad a la recompensa y al castigo, el afecto positivo y negativo, la impulsividad y la personalidad de los participantes mediante pruebas de auto-informe. En relación al aprendizaje, realizan una tarea de aprendizaje de inversión afectivo. Los análisis de varianza muestran la escasa relación entre medidas de autoinforme y lo que deberían ser sus correlatos conductuales en el paradigma de inversión afectiva, discutiéndose tanto sus implicaciones teóricas como aplicadas

The aim of this research is to study sensitivity to reward and punishment patterns in a learning and their relation to different personality dimensions in a sample of 81 female victims of intimate partner violence. Sensitivity to reward and punishment, positive and negative affection, impulsivity and personality of the articipants are all evaluated through self-report evidence. In order to assess the impact upon learning, an emotional reversal learning task is performed. The ANOVA (analysis of variance) tests that were run show little relationship between self-report measures and what their behavioral correlates should be in the affective reversal learning paradigm, discussing both theoretical and applied implications

Miopatía amiloidea como causa de insuficiencia respiratoria / Respiratory failure caused by amyloid myopathy

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Autoestima y sexualidad en adolescentes: validación de una escala / Self steen in teenagers scale validate selfsteem among youth

La autoestima es la forma en la que cada ser se valora y por ende confía en sí mismo; por esto su importancia es crucial en la toma de decisiones de cada individuo, tal es el caso de la decisión de quedar en embarazo a determinada edad.El presente estudio trata de validar un test en adolescentes para evaluar la autoestima.Metodología:Efectuamos una revisión bibliográfica y decidimos realizar una validación cultural del test Área –Specific Self Steem Scale, editado por el Centro de Control de Enfermedades de Atlanta, Georgia1, el cual se dividió en dos partes que identificaban un nivel alto y un nivel bajo de autoestima respectivamente.El test adaptado fue presentado a un colegio de enseñanza media de Alcalá, municipio de 16000 habitantes de la región cafetera de Colombia, perteneciente a la zona norte del departamento del Valle del Cauca.Los resultados fueron analizados por STATA 10.Resultados:El test de identificación de alta autoestima tiene alta confiabilidad (Cronbach=0.737) y el test de baja autoestima tiene una alta confiabilidad (Cronbach=0.82).El test de alta autoestima tiene una capacidad predictiva de 0.709 y el de baja autoestima tuvo una capacidad predictiva cercana al 100 por ciento.Se encontró para el test de alta autoestima una sensibilidad de 96.61 por ciento y una especificidad cercana al 100 por ciento.En la definición de una buena autoestima serían correctamente clasificados el 98.45 por ciento.Conclusiones:Este trabajo valida el test de alta y baja autoestima como una herramienta útil para medir el nivel de autoestima de una población, cuyos resultados sirven como línea de base para intervenciones y posteriores mediciones en trabajos que pretendan mejorar las conductas de riesgo en los adolescentes...