Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism.

BACKGROUND: The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. METHODS: We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. RESULTS: Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. CONCLUSIONS: Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality.

[Importance of the antimicrobial spectrum and the bacterial resistances in the antibiotic choice for the treatment of pediatric patients with communitary infections]. / Importancia de la cobertura antimicrobiana y de las resistencias bacterianas en la elección de antibióticos en Pediatría.

OBJECTIVE: This study aimed to know the importance of the antimicrobial spectrum and the bacterial resistances for the antibiotic choice in the extrahospitalary pediatric area, at the same time that establish the relationship with others therapeutics parameters. MATERIAL AND METHODS: Cross-sectional, observational study within the MUSA (Improvement of Use of Antimicrobial Agents in Primary Health Care) Project made by personal interview of 210 pediatrician doctors randomly selected with national representation. This target is included in a bigger universe (855 doctors) representative of the most doctors responsible of the antibiotic prescriptions in the extrahospitalary area (sample error of the 3.3% for a 95% confidence interval and maximum response dispersion: p=q=50). The results of the pediatric study were subjected to a comparative analysis with the results of a similar study made ten years ago and with the global results of the general study. The questionnaire used for the interview had two clearly different parts: in the first part, the questions were open with the objective to get spontaneous answers from the participants; the second part had questions with suggested answers. RESULTS: Clinical efficacy is the most spontaneously valued issue by the Spanish pediatricians when it comes to choosing an antimicrobial agent; efficacy is followed by tolerance/safety and posology. Antimicrobial spectrum is mentioned by one out of 4-5 pediatricians that have participated in the study (21.9%), while the bacterial resistances are only mentioned by a 3.8%. In a suggested level, clinical efficacy is still the most valued parameter, being identified by 7 out of 10 interviewed with the bacterial eradication. In this case, the antimicrobial spectrum is the following parameter on significance, appearing as a synonym of "activity against specific microorganisms" in 2 out of 3 cases. In relation to his own evaluation, 3 out of 4 pediatricians say they take "a lot" of the bacterial resistances into consideration, who are mostly understood as "global rate" for 5-6 out of 10 interviewed, whether the resistance showed by the pneumococcal is what worried the most to 4 out of 10 of them. This importance given to the bacterial resistances at the second part of the study contrasts with the low consideration showed when it is compared with other parameters and the valoration is treated in a spontaneous way. In relation to a similar study realized on 1997 (Urano Proyect), we observe that clinical efficacy has replaced tolerance/safety as a parameter to bear in mind, probably as a consequence of more experience and confidence with the most important antimicrobial agents in the antibiotic prescriptions in podiatry. On the other hand, the bacterial resistances still being left out on the pediatricians spontaneous consideration, a fact that is shared with the majority of the collectives participating on the general study. The rest of the parameters stay in a similar way. CONCLUSIONS: Is necessary to emphasize at the importance of bacterial resistances in the antimicrobials rational use on the pediatric patient. As the antimicrobial tolerance profile has been improving in the last ten years, clinical efficacy, understood as "bacterial eradication" has became the most determining parameter when choosing antimicrobial agents.

Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial.

OBJECTIVE: Evaluate the efficacy of acupuncture associated with physiotherapy for patients with painful shoulder. METHODS: In a multicentre controlled randomized study, participants were recruited with a clinical diagnosis of unilateral subacromial syndrome from six rehabilitation medicine departments belonging to the Public Health System in two Spanish regions. All participants received 15 sessions of physiotherapy during the 3 weeks that the treatment lasted and were randomized to additionally receive, once a week, acupuncture or mock TENS (transcutaneous electrical nerve stimulation). The primary outcome measure was the change in the Constant-Murley Score (CMS) for functional assessment of the shoulder, at 4 weeks after randomization. This study is registered as an International Standard Randomized Controlled Trial, number ISRCTN28687220. RESULTS: A total of 425 patients were recruited. The mean score (s.d.) on the CMS had increased by 16.6 (15.6) points among the acupuncture group, compared with 10.6 (13.5) points in the control group, and the mean difference between the two groups was statistically significant (6.0 points; 95% CI 3.2, 8.8 points; P < 0.001). By the end of the treatment, 53% of the patients in the acupuncture group had decreased their consumption of analgesics, compared with a corresponding 30% among the control group (P < 0.001). CONCLUSIONS: Single-point acupuncture in association with physiotherapy improves shoulder function and alleviates pain, compared with physiotherapy as the sole treatment. This improvement is accompanied by a reduction in the consumption of analgesic medicaments.

[Knowledge and attitude of primary health care doctors in the treatment of community-acquired infections]. / Conocimiento y actitud de los médicos de atención primaria en el tratamiento de las infecciones comunitarias.

The aim of this study was to evaluate the knowledge and attitude of the doctors who attend patients with community-acquired infections and who are responsible for most of the antibiotic prescriptions in primary health care. At the same time, the evolution experienced in the last ten years in relation to the main parameters analyzed was studied. The study was conducted by personal interviews, using a structured questionnaire, administered to 855 doctors of different specialties, who make up a statistically significant nationwide sample. The study showed that in spite of the improvements in the knowledge of the microbiology of infectious diseases and the choice of antimicrobial agents, there are still certain areas that need improvement. These are, above all, in regard to the bacterial resistance problem, underevaluation of the viral etiology of certain respiratory tract infections and the somewhat condescending attitude with "visits by third parties", indulgence prescriptions and therapeutic noncompliance. Efficacy defined not only as clinical remission but also, and essentially, as antibacterial coverage, are the main parameters considered when participating physicians choose an antibiotic.

Colaboración interdisciplinaria para la mejora de la adherencia y la seguridad del paciente en atención primaria / Interdisciplinary collaboration to improve adherence and patient safety in primary care

JUSTIFICACIÓN: se estima que aproximadamente la mitad de los pacientes crónicos en países desarrollados no son adherentes al tratamiento, lo que supone un problema de salud pública muy prevalente, pues afecta al éxito del tratamiento. Esta falta de adherencia, unida a la inercia clínica puede comprometer la seguridad del paciente. Ante esta situación, los grupos GIS y Seguridad del paciente de SEMERGEN y SEFAC respectivamente entendieron que la situación se presentaba como una oportunidad para que ambas profesiones sanitarias, médicos y farmacéuticos, participasen en una formación conjunta. De esta manera se puso en marcha el curso “Reto Adherencia terapéutica y Seguridad del paciente”(6,6 créditos de formación continuada), actividad basada en el concepto de gamificación donde los participantes obtienen puntos por cada entregable y tema superado, adquiriendo conocimientos y estableciéndose una clasificación con los mejores participantes semana a semana.OBJETIVO: mejorar el conocimiento de las diferentes competencias, así como buscar líneas de mejora conjuntas entre medicina y farmacia, logrando a su vez un mejor control de las patologías de nuestros pacientes.MATERIAL Y MÉTODOS: se han incluido 8 retos en total, 1 tema por semana, entre enero y marzo del año en curso, incluyendo temas relacionados con concepto, prevalencia e importancia de la adherencia, métodos de diagnóstico, propuestas de mejora, inercia clínica, gestión del medicamento: conciliación y de prescripción, seguridad del paciente: conceptos generales y herramientas para la seguridad del paciente; seguridad del paciente en el uso de los medicamentos, coordinación asistencial en adherencia y seguridad. Además de contenidos teóricos y la bibliografía de apoyo. (AU)

[Treatment of encephalopathy by means of valproic acid with carglumic acid: two case reports and a review of the literature]. / Tratamiento de la encefalopatia por acido valproico con acido carbaglumico: descripcion de dos casos y revision de la bibliografia.

INTRODUCTION: Valproic acid (VPA) is a drug mainly used to treat epilepsy. Hyperammonaemic encephalopathy due to VPA is a rare but serious complication. The mechanism by which VPA influences the increase in ammonia consists in blocking the urea cycle, thereby inhibiting N-acetylglutamate synthase and diminishing acetyl coenzyme A. Generally, the treatment employed has been to withdraw VPA and to administer arginine, carnitine, antibiotics, glucose and protein restriction. Previous experience with carglumic acid is limited to reports of isolated cases of paediatric patients. CASE REPORTS: We report the cases of two adult patients with encephalopathy due to VPA who were treated with carglumic acid, in addition to the conventional measures. Following treatment with the drug, ammonia levels can be seen to return to normal values. In one of the two cases, owing to the existence of another cause of encephalopathy, no clinical improvement was observed. CONCLUSIONS: From the biochemical point of view, treating encephalopathy due to VPA with carglumic acid is a logical step, as it reverses the blockage of the urea cycle conditioned by VPA. The mechanism proposed as being the one by which brain toxicity and, therefore, encephalopathy are produced is the passage of ammonia in the form of glutamine to the inside of the cell, which then returns to ammonia and glutamate in the mitochondria and leads to oxidative stress. Carglumic acid must be considered an important part of the treatment in adult patients with hyperammonaemic encephalopathy due to VPA, although a randomised clinical trial needs to be conducted with the drug in order to test its efficacy.

TITLE: Tratamiento de la encefalopatia por acido valproico con acido carbaglumico: descripcion de dos casos y revision de la bibliografia.Introduccion. El acido valproico (VPA) es un farmaco principalmente usado en la epilepsia. La encefalopatia hiperamoniemica por VPA es una complicacion grave e infrecuente. El mecanismo por el que el VPA influye en la elevacion del amonio es bloqueando el ciclo de la urea, inhibiendo la N-acetilglutamato sintasa y disminuyendo la acetil coenzima A. De forma general, el tratamiento que se ha empleado ha sido la suspension del VPA y la administracion de arginina, carnitina, antibioticos, glucosa y restriccion proteica. La experiencia con acido carbaglumico se limita a comunicaciones de casos aislados de pacientes pediatricos. Casos clinicos. Descripcion de dos casos de pacientes adultos con encefalopatia por VPA tratados, ademas de las medidas convencionales, con acido carbaglumico. Tras el tratamiento con el farmaco se aprecia una normalizacion de los niveles de amonio. En uno de los casos, al existir otra causa de encefalopatia, no se aprecio mejora clinica. Conclusiones. Desde el punto de vista bioquimico es logico tratar la encefalopatia por VPA con acido carbaglumico, ya que revierte el bloqueo del ciclo de la urea condicionado por el VPA. El mecanismo propuesto por el que se produce la toxicidad cerebral y, por tanto, la encefalopatia, es el paso de amonio en forma de glutamina al interior celular, que retorna a amonio y glutamato en la mitocondria y genera estres oxidativo. El acido carbaglumico ha de considerarse como parte importante del tratamiento en pacientes adultos con encefalopatia hiperamoniemica por VPA, aunque es necesario realizar un ensayo clinico aleatorizado con el farmaco para comprobar su eficacia.

Efecto de un equipo multidisciplinar (código TEP) en el pronóstico de los pacientes con tromboembolia de pulmón aguda sintomática / Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism

Antecedentes No se han aclarado suficientemente los beneficios del manejo multidisciplinar (código TEP) de los pacientes con tromboembolia de pulmón (TEP) aguda sintomática. El objetivo de este estudio fue evaluar el efecto sobre la mortalidad a corto plazo del código TEP comparado con la atención habitual. Métodos Realizamos un estudio retrospectivo que incluyó a todos los pacientes con diagnóstico de TEP aguda sintomática ingresados en un hospital terciario universitario entre los años 2007 y 2022. Mediante un análisis de emparejamiento exacto 1:1, los pacientes atendidos por un equipo multidisciplinar para el manejo de la TEP (código TEP) fueron emparejados con otros que recibieron la atención habitual (es decir, no multidisciplinar) para la TEP. El evento primario de eficacia fue la mortalidad por cualquier causa durante los 30 primeros días después del diagnóstico. El evento secundario de eficacia fue la mortalidad por la propia TEP durante el mismo período de tiempo. Resultados De los 2.902 pacientes con diagnóstico de TEP aguda sintomática incluidos en este estudio, 223 (7,7%; intervalo de confianza [IC] del 95%: 6,7-8,7%) fueron manejados por el código TEP. Se emparejaron 207 pacientes manejados por el código TEP con 207 pacientes manejados de forma habitual. En la cohorte emparejada, la atención multidisciplinar a los pacientes con TEP aguda sintomática no se asoció a una reducción significativa de la mortalidad por cualquier causa (odds ratio [OR]: 1,09; IC del 95%: 0,63-1,89) o por la propia TEP (OR: 1,30; IC del 95%: 0,47-3,62) en el mes posterior al diagnóstico de la TEP. Conclusiones La atención multidisciplinar a los pacientes con TEP aguda sintomática no se asoció a una reducción significativa de la mortalidad precoz. (AU)

Background The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. Methods We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. Results Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. Conclusions Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality. (AU)

[Treatment of encephalopathy by means of valproic acid with carglumic acid. Reply]. / Tratamiento de la encefalopatia inducida por acido valproico con acido carbaglumico. Replica.

TITLE: Tratamiento de la encefalopatia inducida por acido valproico con acido carbaglumico. Replica.

TIBOLA: presentación de un caso clínico de esta entidad emergente / TIBOLA: reporting of a new clinical case of this emergent entity

Las rickettsiosis se encuentran dentro de las denominadas enfermedades emergentes. En nuestro país, el principal agente etiológico es Rickettsia conorii, que produce, en los meses de verano, una característica costra negra en el punto de inoculación y se acompaña de fiebre y exantema cutáneo. Algunas especies recientemente descubiertas de Rickettsia, como Rickettsia slovaca, producen cuadros clínicos con características diferentes respecto a la fiebre botonosa mediterránea. Ante un cuadro de linfadenitis y antecedente de picadura de garrapata debe sospecharse el cuadro clínico conocido como TIBOLA (tick-borne lymphadenopathy) o DEBONEL (Dermacentor-borne, necrosis, erithema, lymphadenopathy). El principal vector, Dermacentor marginatus, se encuentra en toda España, aunque la mayoría de casos publicados proceden del norte del país. Describimos el caso de un niño de 3 años de edad, con un bultoma cervical anterior de gran tamaño, localizado en la línea media, y se analizan los hallazgos clínicos y analíticos encontrados, así como el diagnóstico serológico (AU)

Rickettsioses are emerging diseases. In our country, the main causative agent is Rickettsia conorii. Some of the pathogenic species of Rickettsia, like Rickettsia slovaca, cause clinical profile with different characteristics respect to the Mediterranean spotted fever. In presence of lymphadenopathy and inoculation eschar associated should be suspected the clinical profile known as TIBOLA (tick-borne lymphadenopathy) or DEBONEL (Dermacentor-terminal, necrosis, erithema, lymphadenopathy). The main vector, Dermacentor marginatus, is found throughout Spain, although most of published cases are from the north of the country. We report the case of a 3 years old male with middle-sided cervical adenopathic conglomerate, and discusses the clinical and analytical findings and diagnosis confirmation with serological test(AU)

Tetania neonatal por hipocalcemia secundaria a hipovitaminosis D. Forma extrema de una enfermedad que resurge / Neonatal hypocalcemic tetany due to vitamin D deficiency. Extreme form of a re-emerging disease

Desde el inicio de la era industrial, el raquitismo ha sido una enfermedad endémica. Con el descubrimiento de la vitamina D y el aporte de suplementos, sobre todo en las fórmulas lácteas infantiles, prácticamente había desaparecido, pero durante los últimos años parece haberse convertido de nuevo en un problema de salud pública. La carencia de vitamina D se asocia no sólo a problemas óseos, sino también a un importante incremento del riesgo de enfermedades cardiovasculares, autoinmunes, infecciosas y tumorales. Comunicamos un caso de tetania neonatal por hipocalcemia secundaria a hipovitaminosis D en un neonato de menos de 2 días de vida. La precocidad de la aparición y la gravedad clínica son excepcionales. Además, advierte del problema emergente que constituye el déficit de vitamina D y de la necesidad de instaurar la suplementación con ésta vitamina, siguiendo las últimas recomendaciones de la Asociación Española de Pediatría (AU)

Since industrial revolution, rickets has been an endemic disease. Since the discovery of vitamin D and its supplements, above all in milk formulates, practically it was disappear, but in the last few years it seems to be again a public health problem. Vitamin D deficiency contributes, not only to bone problems, but also to an important increase in the risk of cardiovascular, autoimmune, infectious diseases and cancer. We communicate a case of neonatal hypocalcemic tetany secondary to a vitamin D deficiency that appeared in a neonate before the second day of life. The precocity of its appearance and its clinical severity are exceptional. It also warn of the emergent problem that it suppose the vitamin D deficiency and the necessity of set up the supplementation with this vitamin, following the last recommendations of the Spanish Paediatrics Association (AU)

Convulsión hiponatrémica con parada respiratoria de etiología poco común / Hyponatremic seizure with respiratory arrest uncommon etiology

Las crisis convulsivas pueden ser la primera manifestación de una patología insospechada. Junto con el tratamiento anticonvulsivo, es necesario un protocolo de actuación dirigido a descartar y tratar las posibles causas reversibles. Las convulsiones por hiponatremia son una manifestación de máxima gravedad con claro riesgo vital, por lo que es necesaria una rápida actuación que eleve la natremia y la osmolaridad a cifras de seguridad. Una causa infrecuente de hiponatremia en los lactantes es la pérdida renal de sodio, secundaria a una infección del tracto urinario. Su origen parece deberse a una resistencia a la acción de la aldosterona en los túbulos renales. Presentamos el caso clínico de un lactante de 49 días de vida, que presentó una crisis convulsiva y una parada respiratoria en el contexto de una hiponatremia grave (Na+: 110 mEq/L). El urocultivo confirmó una pielonefritis por Enterobacter aerogenes, y la ecografía una pielocaliectasia bilateral con cistografía normal, sin evidencia de reflujo vesiculoureteral(AU)

Seizures may be the first symptom of an unsuspected pathology. Anticonvulsant treatment also requires a protocol of action aimed at dismissing and treating any possible reversible causes. Seizures caused by hyponatremia are extreme severity life-threatening manifestations and urgent action is required in order to rise serum sodium and osmolarity to security levels. A rare cause of hyponatremia in infants is the sodium loss secondary to urinary tract infection. Its origin is due to a tubular renal resistance to the action of aldosterone in children with urinary infections. We would like to report the case of a 49-day infant presenting seizure and respiratory arrest in the context of severe hyponatremia. Enterobacter aerogenes growth in the urine culture confirmed pyelonephritis and the ultrasound scan showed a bilateral pyelocaliectasis with normal cystography, not showing vesicouretal reflux(AU)

Importancia de la cobertura antimicrobiana y de las resistencias bacterianas en la elección de antibióticos en Pediatría / Importance of the antimicrobial spectrum and the bacterial resistances in the antibiotic Choice for the treatment of pediatric patients with comunitary infections

Objetivo. Conocer la importancia de la cobertura antimicrobianay de las resistencias bacterianas, así como su relacióncon otros parámetros terapéuticos, a la hora de elegirun tratamiento antimicrobiano en pacientes pediátricos.Material y métodos. Estudio obsevacional transversal,enmarcado en el Proyecto MUSA (Mejora del Uso de los Antimicrobianos)en la atención primaria de salud, realizadomediante entrevista personal a 210 pediatras, seleccionadosde forma aleatoria, con representatividad a nivel nacional.Esta muestra fue extraída de otra mayor (855 médicos), querepresentaba a la práctica totalidad de médicos responsablesde la prescripción de antimicrobianos en el ámbito extrahospitalario(error muestral del 3,3% para un margen de confianzadel 95% y un grado de dispersión de respuesta máximo:p=q=50).Los resultados del estudio en pediatría se sometieron a unanálisis comparativo con los obtenidos con un estudio de lasmismas características realizado 10 años atrás y con los resultadosglobales del estudio general.El cuestionario utilizado en la entrevista tenía dos partesclaramente diferenciadas: en la primera de ellas, se tratabade preguntas abiertas con objeto de conseguir respuestas espontáneasde los participantes; la segunda parte, conteníacuestiones con respuestas sugeridas.Resultados. La eficacia clínica es el aspecto más valoradode forma espontánea por los pediatras españoles a la hora deelegir un antimicrobiano; a la eficacia, le siguen la tolerancia/seguridad y la posología. La cobertura antimicrobiana escitada por uno de cada 4-5 pediatras participantes en el estudio(21,9%), mientras que las resistencias bacterianas sóloson citadas por el 3,8% (AU)

Objective. This study aimed to know the importanceof the antimicrobial spectrum and the bacterial resistances for the antibiotic choice in the extrahospitalarypediatric area, at the same time that establish the relationshipwith others therapeutics parameters.Material and methods. Cross-sectional, observationalstudy within the MUSA (Improvement of Use of AntimicrobialAgents in Primary Health Care) Project made bypersonal interview of 210 pediatrician doctors randomlyselected with national represantitivity. This target is includedin a bigger universe (855 doctors) representativeof the most doctors responsible of the antibiotic prescriptionsin the extrahospitalary area (sample error ofthe 3,3 % for a 95 % confidence interval and maximumresponse dispersion: p=q=50).The results of the pediatric study were subjected to acomparative analysis with the results of a similar studymade ten years ago and with the global results of thegeneral study.The questionnaire used for the interview had twocrearly differenced parts: in the first part, the questionswere open with the objective to get spontanious answersfrom the participants; the second part had questions withsuggested answers.Results. Clinical efficacy is the most spontaneouslyvalored issue by the spanish pediatricians when it comesto choosing an antimicrobial agent; efficacy is followedby tolerance/safety and posology. Antimicrobial spectrumis mentioned by one out of 4-5 pediatricians thathave participated in the study (21,9%), while the bacterialresistances are only mentioned by a 3,8% (AU)