Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care. / Guía de práctica clínica de consenso sobre buenas prácticas en los cuidados al final de la vida de las Sociedades Española y Portuguesa de Medicina Interna.

AIM: To develop consensus recommendations about good clinical practice rules for caring end-of-life patients. METHODS: A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when > 95% answers were completely agree or > 90% were agree or completely agree; and weak consensus when > 90% answers were completely agree or > 80% were agree or completely agree. RESULTS: The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care. CONCLUSIONS: The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.

Antibacterial and non-cytotoxic effect of nanocomposites based in polyethylene and copper nanoparticles.

In this study, an antibacterial, but not cytotoxic nanomaterial based on polyethylene and copper nanoparticles was prepared by in situ polymerization. PE-CuNps nanocomposites against Escherichia coli, completely suppressed the number of live bacteria after 12 h incubation compared to neat PE. TEM images showed that nanocomposites damage the plasma membrane of the bacteria, revealing a bacteriolytic effect. Toxic effects of copper nanoparticles on viability of neuroblastoma line cell also was evaluated, revealing a non cytotoxic effect for the doses used, showing that this nanocomposite is a ideal material for medical devices.

Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care.

AIM: To develop consensus recommendations about good clinical practice rules for caring end-of-life patients. METHODS: A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when >95% answers were completely agree or >90% were agree or completely agree; and weak consensus when >90% answers were completely agree or >80% were agree or completely agree. RESULTS: The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care. CONCLUSIONS: The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.

[Mini nutritional assessment (MNA) as nutrition screening tool in internal medicine. Advantages and disadvantages]. / Cribado nutricional con mini nutritional assessment (MNA) en medicina interna. Ventajas e inconvenientes.

OBJECTIVE: To evaluate the nutritional status of the elderly hospitalized patient with the Mini Nutritional Assessment (MNA), its relationship with length of hospital stay and mortality, the incidence of malnutrition during hospitalization and to evaluate the applicability of MNA in an Internal Medicine Department of an acute care hospital. MATERIAL AND METHODS: A prospective study on the nutritional status of patients of 65 years or older admitted to hospital in an Internal Medicine Department was performed in 106 consecutive patients. In all patients a MNA test, an anthropometric (weight, height, body mass index, skinfold), and biochemical (cholesterol, lymphocytes, albumin) evaluation were performed; outcome, age, institutionalization, Charlson index and Barthel index were recorded. RESULTS: Mean age of the patients was 81±7 years, Charlson index 2.3±1.9 and Barthel index 74.9±30.8. Mean weight was 64.5±10.6kg, BMI 26±3.9, and weight loss in the previous 3 months 1.17±2.92kg. Mean length of hospital stay was 11.1±9.8, and mortality was 5.7%. Prevalence of malnutrition, assessed by MNA, was 4.7%, and 36.8% of the patients were at risk of malnutrition. Malnourished patients have a longer length of hospital stay, higher Barthel and Charlson indexes. There are no conclusive differences in mortality. Incidence of malnutrition during hospitalization was between 2.43 and 15.68%. CONCLUSIONS: Malnutrition increases length of hospital stay, rate of complications and costs. The clinicians responsible for the patient should perform nutrition evaluation at hospital admission and repeat it during the hospitalization, using simple screening tools that incorporate an explicit nutrition intervention plan.

End-of-life care for patients hospitalised in internal medicine departments. / Cuidados en los últimos días de vida en los pacientes hospitalizados en medicina interna.

OBJECTIVES: To describe the care provided at the end of life for patients who die in internal medicine departments. METHODS: An observational, cross-sectional, retrospective multicentre, clinical audit study was conducted where each hospital included the first 10 patients who died in the internal medicine department starting on December 1, 2015. We collected demographic and clinical data and information regarding the circumstances and care at the time of death. RESULTS: The study included 1,447 patients with a median age of 84 years. Of these, 1,065 (74.3%) were polypathological, 751 (51.9%) were terminal and 248 (17.1%) had cancer. For the terminal patients, do-not-resuscitate orders were established for 539 (73.3%), and palliative sedation was performed for 422 (57.4%). There was no record as to whether psychological, religious or grief care was provided in 32%, 64.8% and 44.1% of the terminal patients, respectively. The patients with cancer were more often competent to make decisions (54.4% vs. 15.5%; P<.001), knew their prognosis (42.6% vs. 8.6%; P<.001), received psychological care (24.9% vs. 8.6%; P<.001), died in an individual room (64.6% vs. 44.4%; P<.001) and were accompanied (81.9% vs. 71.9%; P=.003). Their relatives also more frequently received grief care (15.6% vs. 8.2%; P=.002). CONCLUSIONS: There is insufficient recording in the medical history as to the end-of-life care. There are differences in the care provided to patients with cancer and to those without cancer.

[Reason for consultation: Weight loss]. / Motivo de consulta: pérdida de peso.

BACKGROUND AND OBJECTIVE: Unintentional weight loss is frequent reason to visit a doctor and it has multiple diagnostic possibilities. The objective of this study is to examine the background of the patients who seek consultation for weight loss and to establish the relationship between weight loss and neoplasia. METHOD: An analysis was performed on the demographic data, quantified weight loss, accompanying symptomatology, and diagnosis of patients who sought medical advice for unintentional weight loss during the year 2015. RESULTS: A total of 226 patients were included, of whom 44.2% of them had an intentional weight loss ≥ 5% in 6 months. The most frequent diagnosis in this group was a neoplasia, whereas in the rest of patients the most common diagnosis was a gastrointestinal disease. In light of this study we can conclude that there is a relationship between unintentional weight loss≥5% and the presence of neoplasia. CONCLUSION: An unintentional weight loss greater than 5% in the previous 6 months is associated with the presence of neoplastic diseases, and therefore requires further diagnostic study.

[Usefulness of MBDS in detection of adverse drug events]. / Utilidad del CMBD para la detección de acontecimientos adversos por medicamentos.

OBJECTIVE: To analyze the incidence of adverse drug events (ADE) as noted in hospital discharge reports, as well as their potential avoidability, drugs involved, clinical symptoms and the type of medication errors that led to the preventable ADE. MATERIAL AND METHODS: A retrospective study for the January- December 2005 period of time, at a district hospital. ADE were detected in which patients with discharge reports including event codes as defined by the IDC-9-CM system, using the minimum basic data set (MBDS). RESULTS: ADEs were detected in 4.01% of all discharge reports in the study period (n = 160). 45% of ADEs were were detected at the Emergency Department (n = 72) and 55% (n = 88) were detected during hospitalization.62.3% of ADEs were considered potentially avoidable (n = 109). 38.1% of ADEs were serious, 40.0% moderate and 21.9% mild. Drugs most commonly involved in the ADEs sample studied included: antimicrobials (24.0%), systemic corticoids (15.4%), NSAIDs (11.4%), diuretics (10.3%), digoxin (9.1%), insulin and oral hypoglycaemic agents (5.7%), anticoagulants and heparin (5.7%). Inadequate therapy monitoring (47.7%), excessive dosage (28.5%), drug-drug interactions (10.1%) were the most common identified type of errors leading to preventable ADE. CONCLUSIONS: 3.2% of admissions was caused by ADEs. 2.2% of hospitalized patients experienced ADEs. 62% of ADEs were potentially preventable. A high proportion of preventable ADEs were around a small number of drugs. Effective safety practices directed to reduce the incidence of medication errors are needed.

[Identifying gaps between guidelines and clinical practice in Clostridium difficile infection]. / Diferencias entre las recomendaciones y la práctica clínica en la infección por Clostridium difficile.

OBJECTIVES: The first aim was to determine whether patients are being treated in accordance with the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America (IDSA/SHEA) Clostridium difficile guidelines and whether adherence impacts patient outcomes. The second aim was to identify specific action items in the guidelines that are not being translated into clinical practice, for their subsequent implementation. MATERIAL AND METHODS: A retrospective, descriptive study was conducted over a 36 month period, on patients with compatible clinical symptoms and positive test for C. difficile toxins A and/or B in stool samples, in an internal medicine department of a tertiary medical centre. Patient demographic and clinical data (outcomes, comorbidity, risk factors) and compliance with guidelines, were examined RESULTS: A total of 77 patients with C. difficile infection were identified (87 episodes). Stratified by disease severity criteria, 49.3% of patients were mild-moderate, 35.1% severe, and 15.6% severe-complicated. Full adherence with the guidelines was observed in only 40.2% of patients, and was significantly better for mild-moderate (71.0%), than in severe (7.4%) or severe-complicated patients (16.6%) (P<.003). Adherence was significantly associated with clinical cure (57% vs 42%), fewer recurrences (22.2% vs 77.7%), and mortality (25% vs 75%) (P<.01). The stratification of severity of the episode, and the adequacy of antibiotic to clinical severity, need improvement. CONCLUSIONS: Overall adherence with the guidelines for management of Clostridium difficile infection was poor, especially in severe and severe-complicated patients, being associated with worse clinical outcomes. Educational interventions aimed at improving guideline adherence are warranted.

Anesthetic management of placenta accreta in a low-resource setting: a case series.

BACKGROUND: Current recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting. METHODS: A retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted. RESULTS: Thirty-nine cases were identified. Mean (± SD) maternal age was 33 ± 5.4 years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100-2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0-6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred. CONCLUSION: A multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.

Influence of refraction on tonometric readings after photorefractive keratectomy and laser assisted in situ keratomileusis.

PURPOSE: To determine the decrease of Goldmann tonometry after photorefractive keratectomy (PRK) and laser assisted in situ keratomileusis (LASIK) according to refraction prior to surgery. METHODS: Prospective simultaneous comparative case series of 53 myopic eyes (53 patients) that underwent PRK and 50 (50 patients) that underwent LASIK using the Summit Excimed SVS plus (Summit Technology, Inc., Walthan, MA, U.S.A.). PRK and LASIK were subdivided by refractive error into two subgroups of more than or less than -5 diopters (D). Central tonometric readings were taken prior to surgery and 12 months after surgery. RESULTS: In LASIK and PRK subgroups of more than -5 D, 85.7% (24) and 69.6% (24), respectively, gave lower readings than those taken before surgery. In LASIK and PRK subgroups of less than -5 D, 77.3% (17) and 53.3% (16), respectively, gave lower readings. The difference between the two is significant (p < 0.001). Average tonometry falls by 2.8 mmHG in the LASIK subgroup of more than -5 D (p < 0.001) and by 2.8 mmHG in the LASIK subgroup of less than -5 D (p < 0.001) and by 1.7 mmHG in the PRK subgroup of more than -5 D (p < 0.010). In PRK subgroup of less than -5 D, the tonometric changes are not significant (p = 0.971). CONCLUSIONS: High previous refraction (in PRK) and technique used determines lower final tonometric readings, bringing about more frequent and significant decreases in LASIK than in PRK for errors of more than and less than -5 D.

Crystals occurring in pulmonary cytology specimens. Association with Aspergillus infection.

Birefringent needlelike crystals in rosette or wheat-sheaf-like arrangements were found in pulmonary cytology specimens from 11 of 65 patients who had either sputum cultures positive for Aspergillus or histologically confirmed pulmonary aspergilloma. No crystals were found in specimens from 60 control patients with and without known fungal disease. The crystals were most often associated with A. niger infection (45.4%), followed by A. flavus (16%). Crystals were also observed in one case of A. fumigatus infection and in one case in which the species was not determined. In two cases, crystals were found more than one year before sputum cultures became positive; in one of these patients, a fungus ball was not identified by X ray until five years after the first appearance of the crystals in the sputum. Sixty-four percent of the patients with crystals also showed moderate to severe cytologic atypia. The crystals are thought to be calcium oxalate. We conclude that the presence of birefringent needlelike crystals with rosette or wheat-sheaf-like arrangements in pulmonary cytology specimens is a reliable marker for the presence of Aspergillus infection, which may be detected before cultures are positive or a fungus ball is evident on X ray.

[Peritoneal pseudomyxoma secondary to mucinous cystadenoma of the ovary]. / Pseudomixoma peritoneal secundario a cistoadenoma mucinoso de ovario.

We present a new case of pseudomyxoma peritonei secondary to a mucinous cystadenoma of the ovary, whose presenting symptoms were abdominal distension and bilateral hernias. This is an uncommon entity and diagnosis tends to be casual. Each day, ultrasonography and computed tomography are more useful in suspicion. Aggressive surgical debulking followed by intraperitoneal chemotherapy seem to be the better treatment, even though controversies persist.

[Relapsing polychondritis with atypical presentation]. / Policondritis recidivante de presentación atípica.

Relapsing polychondritis is an episodic systemic disorder, characterized by recurrent inflammation that affects cartilaginous structures, the cardiovascular system, eyes and ears. Although the etiology is unknown, experimental evidence strongly suggest that immunologically mediated mechanisms are implicated. Auricular, articular and nasal manifestations are the most frequent disturbances. In about 30% of cases, relapsing polychondritis is associated with other connective tissue diseases and vasculitis. Actually, the diagnosis is based on the criteria proposed by McAdam, and modified by Damiani. We present a case, whose first manifestations of relapsing polychondritis were an intermittent fever and transient arthralgias. Eight months later, auricular chondritis appeared, and gave us the key to diagnosis.