Three double-dose reinforced hepatitis B revaccination scheme for patients with cirrhosis unresponsive to the standard regimen: an open-label randomised clinical trial.

OBJECTIVE: We aimed to compare the response rates between two different hepatitis B virus vaccination schedules for cirrhotic subjects who were non-responders to the first three 40 µg doses (month 0-1-2), and identify factors associated with the final response. DESIGN: A total of 120 cirrhotic patients (72.5% decompensated) were randomised at a 1:1 ratio to receive a single 40 µg booster vaccination at month 6 (classical arm) versus an additional round of three new 40 µg doses administered at monthly intervals (experimental arm). The main outcome was the rate of postvaccinal anti-hepatitis B surface antibodies levels ≥10 mIU/mL. RESULTS: Efficacy by ITT analysis was higher in the experimental arm (46.7%) than in the classical one (25%); OR 2.63, p=0.013. The experimental arm increased response rates compared with the classical one from 31% to 68% (OR 4.72; p=0.007), from 24.4% to 50% (OR 3.09; p=0.012) and from 24.4% to 53.8% (OR 3.62; p=0.007), in Child A, Model for End-Stage Liver Disease (MELD) <15 and MELD-Na<15 patients, respectively. Patients with more advanced liver disease did not benefit from the reinforced scheme. Both regimens showed similar safety profiles. Multivariable analysis showed that the experimental treatment was independently response associated when adjusted across three logistic regression models indicating equivalent cirrhosis severity. CONCLUSION: For cirrhotic patients, the revaccination of non-responders to the first three dose cycle, with three additional 40 µg doses, achieved significantly better response rates to those obtained with an isolated 40 µg booster dose. TRIAL REGISTRATION NUMBER: NCT01884415.

[Respiratory syncytial virus outbreak in a tertiary hospital Neonatal Intensive Care Unit]. / Brote por virus respiratorio sincitial en la Unidad de Neonatología de un hospital de tercer nivel.

INTRODUCTION: Investigation and control of a respiratory syncytial virus (RSV) outbreak that affected the Neonatal Intensive Care Unit (NICU) of a university hospital from October to December 2012. PATIENTS AND METHODS: Cohort study of children admitted to the NICU. The infection attack rate was calculated. A descriptive analysis of the cases and a multivariate analysis was performed using the variables that were shown to be risk factors for RSV infection. Preventive measures taken were: contact isolation; hand hygiene training and observation; exclusivity of a health team of nurses and physicians for positive cases, restrictions on visitor numbers; surveillance RSV testing, and palivizumab prophylaxis. RESULTS: The outbreak had three epidemic waves and 20 positive cases out of a total of 48 children admitted. The overall attack rate was 42%. Half of positive cases were children, with a median age of 36 days (p25=22, p75=58). The independent risk factors for RSV infection were birth weight below 1000 grams (OR=23.5; P=.002) and to have another nosocomial infection the week before the diagnosis of RSV infection (OR=19.98; P=.016). CONCLUSIONS: It was an outbreak with a high number of cases, due to the delay in notification, prolonged RSV carrier status, and low adherence to hand hygiene practice, which favoured the cross-transmission of infection. The most effective preventive measures were direct observation of hand hygiene and supervision of isolation measures.

[Practical lessons from the risk management of an outbreak of acute gastroenteritis in a public school]. / Herramientas para afrontar las situaciones de crisis en un brote de gastroenteritis aguda en un colegio público.

We present our reflections on the management of an acute gastroenteritis outbreak in a public school, which caused a public health crisis, and the conclusions drawn from this experience. The methodology of strengths, weaknesses, opportunities, and threats (SWOT) analysis was used. This article describes the epidemiology of the incident and the policy decisions made, but focuses on operational aspects of outbreak management. The experience of the outbreak control team, liaison with other organizations, and data management are discussed. The difficulties encountered by the outbreak team related to delay in declaring in the outbreak, lack of training in some of the entities involved, and incorrect use of the surveillance circuits. Current protocols and specific action plans for the management of outbreaks should be improved through self-evaluation and updating of resources and knowledge.

Hospital costs associated with nosocomial infections in a pediatric intensive care unit.

OBJECTIVE: To estimate the additional cost attributable to nosocomial infection (NI) in a pediatric intensive care unit (PICU) and related factors. METHODS: A prospective cohort study was conducted in all children admitted to the PICU of a tertiary-care pediatric hospital between 2008 and 2009. Descriptive and bivariate analyses were conducted of total direct costs due to PICU stay and medical procedures in patients with and without NI. A log-linear regression model was performed to determine the factors associated with higher total cost. RESULTS: A total of 443 patients were studied and the prevalence of NI was 11.3%. The difference in the median total cost was €30,791.4 per patient between groups with and without NI. The median cost of PICU length of stay in patients with NI was almost eight times higher than the median cost of patients without NI. In patients with NI, the highest costs related to medical procedures were associated with antibiotics, enteral and parenteral feeding, and imaging tests. In the multivariate model, the factors associated with higher cost were infection, the performance of cardiovascular surgery, urgent admission, a higher pediatric risk mortality score, and the presence of immunosuppression. By contrast, older children and those with surgical admission generated lower cost. CONCLUSIONS: NI was associated with an increase in total cost, which implies that the prevention of these infections through specific interventions could be cost-effective and would help to increase the safety of healthcare systems.

Brote por virus respiratorio sincitial en la Unidad de Neonatología de un hospital de tercer nivel / Bedside ultrasound in the critically ill paediatric patient

INTRODUCCIÓN: Investigación y control de un brote por virus respiratorio sincitial (VRS) que afectó a la Unidad de Neonatología (UN) de un hospital universitario de octubre a diciembre del 2012. PACIENTES Y MÉTODOS: Estudio de cohortes de los niños ingresados en la UN. Se calculó la tasa de ataque de infección y se realizaron un análisis descriptivo de los casos y un análisis multivariante de aquellas variables que mostraron ser factores de riesgo de infección por VRS. Las medidas preventivas llevadas a cabo fueron: aislamiento de contacto de casos; formación y observación de higiene de manos; exclusividad del personal sanitario para casos, restricción de visitas; estudio de portadores de VRS y profilaxis con palivizumab. RESULTADOS: El brote tuvo 3 ondas epidémicas y un total de 20 casos, de 48 niños ingresados. La tasa de ataque global fue del 42%. De los casos, la mitad fueron niños, con una edad mediana de 36 días (p25=22, p75=58). El peso al nacimiento inferior a 1.000 g (OR=23,5; p = 0,002) y tener otra infección nosocomial en la semana previa al diagnóstico de infección por VRS (OR=19,98; p = 0,016), fueron factores de riesgo independientes de infección por VRS. CONCLUSIONES: Se trató de un brote epidémico con un elevado número de casos, relacionado con el retraso en la notificación, el tiempo prolongado del estado de portador del VRS y los fallos en el cumplimiento de la higiene de manos, que favoreció la transmisión cruzada de la infección. Las medidas preventivas más eficaces fueron la observación directa de higiene de manos y supervisión de las medidas de aislamiento

INTRODUCTION: Investigation and control of a respiratory syncytial virus (RSV) outbreak that affected the Neonatal Intensive Care Unit (NICU) of a university hospital from October to December 2012. PATIENTS AND METHODS: Cohort study of children admitted to the NICU. The infection attack rate was calculated. A descriptive analysis of the cases and a multivariate analysis was performed using the variables that were shown to be risk factors for RSV infection. Preventive measures taken were: contact isolation; hand hygiene training and observation; exclusivity of a health team of nurses and physicians for positive cases, restrictions on visitor numbers; surveillance RSV testing, and palivizumab prophylaxis. RESULTS: The outbreak had three epidemic waves and 20 positive cases out of a total of 48 children admitted. The overall attack rate was 42%. Half of positive cases were children, with a median age of 36 days (p25=22, p75=58). The independent risk factors for RSV infection were birth weight below 1000 grams (OR=23.5; P=.002) and to have another nosocomial infection the week before the diagnosis of RSV infection (OR=19.98; P=.016). CONCLUSIONS: It was an outbreak with a high number of cases, due to the delay in notification, prolonged RSV carrier status, and low adherence to hand hygiene practice, which favoured the cross-transmission of infection. The most effective preventive measures were direct observation of hand hygiene and supervision of isolation measures

Hospital costs associated with nosocomial infections in a pediatric intensive care unit / Coste asociado a la infección nosocomial en una unidad de cuidados intensivos pediátricos

Objective: To estimate the additional cost attributable to nosocomial infection (NI) in a pediatric intensive care unit (PICU) and related factors. Methods: A prospective cohort study was conducted in all children admitted to the PICU of a tertiary-care pediatric hospital between 2008 and 2009. Descriptive and bivariate analyses were conducted of total direct costs due to PICU stay and medical procedures in patients with and without NI. A log-linear regression model was performed to determine the factors associated with higher total cost. Results: A total of 443 patients were studied and the prevalence of NI was 11.3%. The difference in the median total cost was €30,791.4 per patient between groups with and without NI. The median cost of PICU length of stay in patients with NI was almost eight times higher than the median cost of patients without NI. In patients with NI, the highest costs related to medical procedures were associated with antibiotics, enteral and parenteral feeding, and imaging tests. In the multivariate model, the factors associated with higher cost were infection, the performance of cardiovascular surgery, urgent admission, a higher pediatric risk mortality score, and the presence of immunosuppression. By contrast, older children and those with surgical admission generated lower cost. Conclusions: NI was associated with an increase in total cost, which implies that the prevention of these infections through specific interventions could be cost-effective and would help to increase the safety of healthcare systems (AU)

Objetivo: El objetivo del estudio es estimar el coste adicional atribuible a la infección nosocomial (IN) en una Unidad Pediátrica de Cuidados Intensivos (UCIP) y sus factores asociados. Método: estudio de cohortes prospectivo de todos los pacientes ingresados en una UCIP de tercer nivel entre 2008 y 2009. Se realizó un análisis descriptivo y bivariante del coste total asociados a estancia en UCIP y procedimientos en pacientes con y sin IN. Mediante regresión lineal múltiple, se estimaron los factores asociados al incremento del coste total. Resultados: se estudiaron 443 pacientes, la incidencia de IN fue 11,3%. La diferencia de las medianas en el coste total fue de 30.791,4€ por paciente entre los grupos con y sin IN. El coste mediano de la estancia de pacientes con IN fue casi ocho veces mayor que el coste mediano de los pacientes sin IN. En pacientes con IN, el coste asociado a procedimientos más elevado fue el de antibióticos, nutrición enteral y parenteral y pruebas de imagen. En el modelo multivariante los factores asociados con un mayor coste fueron: presencia de infección nosocomial, cirugía cardiovascular, tipo ingreso urgente, mayor índice pronóstico de mortalidad al ingreso y la presencia de inmunosupresión. Por el contrario, los de mayor edad y aquellos ingresados por cirugía presentaron un menor coste. Conclusiones: La IN está asociada al incremento del coste total, lo que implica que la prevención de estas infecciones mediante intervenciones específicas podría resultar costo-efectiva, redundando en sistemas de salud más seguros (AU)

[Experience of women who request voluntary abortion: relationship with their health care environment]. / Experiencia de mujeres que solicitan interrupción voluntaria del embarazo: relación con el entorno sanitario.

OBJECTIVE: To describe women's perception of health care after they decided to have a voluntary termination of pregnancy and their referral to the abortion clinic. DESIGN: Qualitative method, using semi-structured interviews carried out between April and June 2005. SETTING: Primary Health Care District of Seville, Spain. PARTICIPANTS: Women living in the city of Seville and attending subsidized abortion clinics. MAIN MEASUREMENTS: Thirty-six women of varying ages and educational level were interviewed. The interview studied the assessment and information given by health professionals, and accessibility and use of family planning services. The results were analysed and triangulated with other studies and experts in the field. MAIN RESULTS: Most of the women interviewed were satisfied with the health care provided. Occasionally they perceived a bureaucratic attitude from physicians, who transmitted their disapproval and lack of support for an abortion decision. There were important differences in the way they were referred to abortion clinics, and in the information given to the women. Older women opted for private care, because this accelerated procedures and protected their privacy. Most women did not use family planning services before the abortion decision, except for requesting contraception. CONCLUSIONS: The study found there is a need to reduce the variety of patterns of care for women requesting an abortion, to speed up the proceedings and to train family doctors in assessment and information delivered to women during the process.

Herramientas para afrontar las situaciones de crisis en un brote de gastroenteritis aguda en un colegio público / Practical lessons from the risk management of an outbreak of acute gastroenteritis in a public school

En este trabajo describimos las reflexiones y conclusiones extraídas del análisis de un brote de gastroenteritis en un centro escolar, que ocasionó una crisis de salud pública. El análisis realizado tuvo como base la metodología de las matrices de "debilidades, amenazas, fortalezas y oportunidades" (DAFO). Se describe la epidemiología de los sucesos y decisiones tomadas, basadas en aspectos operativos durante una situación de crisis. Incluye la experiencia del equipo responsable del brote, las relaciones con otras entidades y la gestión de la información. Las dificultades encontradas por el equipo coordinador consistieron en el retraso de la declaración, la falta de formación de algunas entidades implicadas y el mal uso de los circuitos establecidos. Es necesario un entrenamiento específico en los actuales protocolos de manejo de crisis y fomentar la mejora continua de los circuitos de coordinación mediante la autoevaluación y actualización de conocimientos y recursos

We present our reflections on the management of an acute gastroenteritis outbreak in a public school, which caused a public health crisis, and the conclusions drawn from this experience. The methodology of strengths, weaknesses, opportunities, and threats (SWOT) analysis was used. This article describes the epidemiology of the incident and the policy decisions made, but focuses on operational aspects of outbreak management. The experience of the outbreak control team, liaison with other organizations, and data management are discussed. The difficulties encountered by the outbreak team related to delay in declaring in the outbreak, lack of training in some of the entities involved, and incorrect use of the surveillance circuits. Current protocols and specific action plans for the management of outbreaks should be improved through self-evaluation and updating of resources and knowledge

Herramientas para afrontar las situaciones de crisis en un brote de gastroenteritis aguda en un colegio público / Practical lessons from the risk management of an outbreak of acute gastroenteritis in a public school

En este trabajo describimos las reflexiones y conclusiones extraídas del análisis de un brote de gastroenteritis en un centro escolar, que ocasionó una crisis de salud pública. El análisis realizado tuvo como base la metodología de las matrices de "debilidades, amenazas, fortalezas y oportunidades" (DAFO). Se describe la epidemiología de los sucesos y decisiones tomadas, basadas en aspectos operativos durante una situación de crisis. Incluye la experiencia del equipo responsable del brote, las relaciones con otras entidades y la gestión de la información. Las dificultades encontradas por el equipo coordinador consistieron en el retraso de la declaración, la falta de formación de algunas entidades implicadas y el mal uso de los circuitos establecidos. Es necesario un entrenamiento específico en los actuales protocolos de manejo de crisis y fomentar la mejora continua de los circuitos de coordinación mediante la autoevaluación y actualización de conocimientos y recursos

We present our reflections on the management of an acute gastroenteritis outbreak in a public school, which caused a public health crisis, and the conclusions drawn from this experience. The methodology of strengths, weaknesses, opportunities, and threats (SWOT) analysis was used. This article describes the epidemiology of the incident and the policy decisions made, but focuses on operational aspects of outbreak management. The experience of the outbreak control team, liaison with other organizations, and data management are discussed. The difficulties encountered by the outbreak team related to delay in declaring in the outbreak, lack of training in some of the entities involved, and incorrect use of the surveillance circuits. Current protocols and specific action plans for the management of outbreaks should be improved through self-evaluation and updating of resources and knowledgeWe present our reflections on the management of an acute gastroenteritis outbreak in a public school, which caused a public health crisis, and the conclusions drawn from this experience. The methodology of strengths, weaknesses, opportunities, and threats (SWOT) analysis was used. This article describes the epidemiology of the incident and the policy decisions made, but focuses on operational aspects of outbreak management. The experience of the outbreak control team, liaison with other organizations, and data management are discussed. The difficulties encountered by the outbreak team related to delay in declaring in the outbreak, lack of training in some of the entities involved, and incorrect use of the surveillance circuits. Current protocols and specific action plans for the management of outbreaks should be improved through self-evaluation and updating of resources and knowledge

Experiencia de mujeres que solicitan interrupción voluntaria del embarazo: relación con el entorno sanitario / Experience of women who request voluntary abortion: relationship with their healthcare environment

Objetivo. Describir cómo perciben las mujeres la asistencia sanitaria recibida tras la decisión de someterse a una interrupción voluntaria del embarazo (IVE) y su derivación a la clínica de aborto. Diseño. Diseño cualitativo mediante entrevistas semiestructuradas realizadas en 2005. Emplazamiento. Distrito Sanitario de Atención Primaria de Sevilla. Participantes. Mujeres residentes en la ciudad de Sevilla que acudieron a las clínicas de aborto concertadas. Mediciones principales. Se realizaron 36 entrevistas segmentadas por grupos de edad y nivel de estudios. Categorías de análisis: trato e información recibidos, accesibilidad y uso de las consultas de planificación familiar. Se realizó un análisis de contenido y triangulación de resultados con otros estudios y expertos en la materia. Resultados principales. La mayoría de las entrevistadas se muestran satisfechas con la asistencia recibida. En ocasiones refieren que la actitud del médico de familia es burocrática, y les ha transmitido su desacuerdo y falta de apoyo en su decisión de abortar. No se identificó un circuito único de derivación a las clínicas ni una homogeneidad en la información suministrada a las mujeres. Las de mayor edad optaron por la asistencia privada, refiriendo que acelera los trámites y preserva su intimidad. La mayoría de las mujeres no utilizó previamente las consultas de planificación familiar, excepto para solicitar métodos anticonceptivos. Conclusiones. Se constata la necesidad de disminuir la variabilidad en la asistencia a las mujeres que solicitan una IVE, agilizar los trámites y formar a los médicos de familia en el tratamiento y la información que la mujer demanda en el proceso de IVE

Objective. To describe women's perception of health care after they decided to have a voluntary termination of pregnancy and their referral to the abortion clinic. Design. Qualitative method, using semi-structured interviews carried out between April and June 2005. Setting. Primary Health Care District of Seville, Spain. Participants. Women living in the city of Seville and attending subsidised abortion clinics. Main measurements. Thirty-six women of varying ages and educational level were interviewed. The interview studied the assessment and information given by health professionals, and accessibility and use of family planning services. The results were analysed and triangulated with other studies and experts in the field. Main results. Most of the women interviewed were satisfied with the health care provided. Occasionally they perceived a bureaucratic attitude from physicians, who transmitted their disapproval and lack of support for an abortion decision. There were important differences in the way they were referred to abortion clinics, and in the information given to the women. Older women opted for private care, because this accelerated procedures and protected their privacy. Most women did not use family planning services before the abortion decision, except for requesting contraception. Conclusions. The study found there is a need to reduce the variety of patterns of care for women requesting an abortion, to speed up the proceedings and to train family doctors in assessment and information delivered to women during the process