Systematic review and meta-analysis of performance of second-trimester nasal bone assessment in detection of fetuses with Down syndrome.

OBJECTIVE: To review systematically the literature on diagnostic tests and performance of second-trimester sonographic assessment of nasal bone (NB) in identifying fetuses affected by Down syndrome. METHODS: A search of studies involving screening tests for NB evaluation and measurements was carried out in the main international bibliographic databases (MEDLINE, EMBASE and CINAHL). Those considered to be relevant were then subjected to critical reading, following Critical Appraisal Skills Programme (CASP) criteria, by at least three independent observers. All data were extracted and tabulated by two independent investigators. A statistical synthesis of sensitivity, specificity and likelihood ratios was performed using specific software (Meta-DiSc). RESULTS: From an initial list of 852 articles referring to ultrasound markers for Down syndrome, 207 relevant papers were selected. Following exclusions, 21 studies were included in the quantitative synthesis. The pooled estimates of positive and negative likelihood ratios were 40.08 (95% CI, 18.10-88.76) and 0.71 (95% CI, 0.64-0.79), respectively, for absent NB and 15.15 (95% CI, 8.15-28.16) and 0.47 (95% CI, 0.34-0.64), respectively, for hypoplastic NB. No relevant differences were found between the various means of defining nasal hypoplasia (multiples of the median (MoM) or percentiles). The biparietal diameter/nasal bone length (BPD/NBL) ratio showed somewhat higher sensitivity but lower specificity with a threshold effect. CONCLUSIONS: NB absence or hypoplasia show high specificity and low but acceptable sensitivity in identifying fetuses with Down syndrome. Screening performance is better with NB measurements as a function of MoM or percentiles rather than as the BPD/NBL ratio. Classification of women into various risk groups for Down syndrome does not affect diagnostic performance.

[Results of the implementation of an Antimicrobial Stewardship Program in the "Gerencia de Atención Integrada" of Alcazar de San Juan (Castilla La Mancha)]. / Resultados de la implantación de un Programa de Optimización de Antimicrobianos en la Gerencia de Atención Integrada de Alcázar de San Juan (Castilla La Mancha).

OBJECTIVE: Our aim was to evaluate the efficiency of an ASP after its implementation in 2016 in a Spanish hospital quality system. METHODS: Efficiency of the ASP was measured by process and outcome indicators at the level of the patient's quality of life, antimicrobial consumption and percentage of resistance to them during the 2016-2017 period. In 2017, the failures mode and effects analysis (FMEA) methodology was applied. An annual satisfaction survey was conducted. RESULTS: The clinical indicators were within the threshold of acceptability, as well as the empirical prescription of antimicrobials, the consumption of antibiotics (reduction of 77 DDD in the first semester of 2016 to 26 in the second semester of 2017) and the renal (gentamicin) and neurological (carbapenems) toxicity. The FMEA identified as a main risk the lack of adequacy of the empirical treatment once the antibiogram was obtained; thus, a corrective action was taken in 2017. Regarding the microbiological indicators, the incidence of multi-drug resistant and carbapenemase-producing enterobacteria, and that of methicillin-resistant Staphylococcus aureus, were reduced. Eighty-three percent of the counselling activities carried out were accepted. The surveys revealed a good acceptance and spread of the program, the need for protocols and training in the use of antibiotics. CONCLUSIONS: The implementation of the ASP in the quality system was efficient. The consumption of antibiotics and the adverse effects derived from their use were reduced, improving the quality of life of patients, and reducing health costs.

[Monoclonal spread of multi-drug resistant CTX-M-15-producing Klebsiella pneumoniae. Impact of measures to control the outbreak]. / Diseminación monoclonal de Klebsiella pneumoniae productora de CTX-M-15 multirresistente. Impacto de las medidas para controlar el brote.

OBJECTIVE: To describe an outbreak of multi-drug resistant extended-spectrum ß-lactamases-producing Klebsiella pneumoniae (MDR-ESBL-KPN) and the impact of measures for its control. METHODS: We reviewed the patients´ clinical records with MDR-ESBL-KPN isolation during 2013-2016 with resistance to fluoroquinolones, aminoglycosides, fosfomycin, and nitrofurantoin; susceptible to imipenem, meropenem, colistin, and tigecycline and variable to ertapenem and cotrimoxazole (Vitek-2). The genetic relationship between 35 isolates was established by PFGE and MLST. Control measures were put in place in January 2016. RESULTS: We detected 269 patients colonized and/or infected by KPN-ESBL-MDR with a common resistance phenotype; the strains studied carried the blaCTX-M-15 gene and formed a single cluster belonging to ST11. The outbreak was detected at the end of 2015, although it began in 2013 in an elderly center. The acquisition source of the strains was: 6% community-acquired, 37% hospital-acquired (76% in internal medicine) and 57% related to long health care facilities (78% of hospitalizations in the last year). Ninety-four percent of patients had at least one underlying disease, 90% received antibiotics previously and 49% had some invasive devices. After the introduction of control measures, the incidence of cases in the quarter was reduced from 29 to 15. CONCLUSIONS: We detected a monoclonal outbreak of MDR-CTX-M-15-KPN in 2015, with predominance of health-care associated cases. The success in the rapid spread of the outbreak was due to the delay in its detection and to the fact that most of the patients had previously received antibiotics. The control measures reduced the number of isolates by 50%.