[The value of human resources: experience of critical care nurses during the COVID-19 epidemic]. / El valor del recurso humano: experiencia de profesionales enfermeros de cuidados críticos durante la pandemia por COVID-19.

The COVID-19 pandemic has caused an unprecedented health crisis. Pressure on the National Health System has created unique demand particularly in certain services and care units like the critical care units. Objective: To learn about the experience of nurses in caring for people with coronavirus in critical care units. Method: A qualitative phenomenological study that constitutes the second phase of a mixed methodology project. We conducted interviews with 17 nurses caring for patients affected by COVID-19 in critical care units. The interviews were audio-recorded, transcribed, and analysed using thematic discourse analysis. Results: This article shows the findings around the theme "the value of human resources" which is nuanced through sub-themes "it's not the beds, it's the expert staff", "shouldering the patient's burden", and suffering because "they have not cared well". Discussion: Expert nurses have emerged as leading professionals in the care of the critical patient during the COVID-19 pandemic. This leadership is executed from a profile framed in an inclusive philosophy where wisdom, agility and intuition are the key elements underpinning problem identification and solving in a creative way, while adapting to the needs of the patient and healthcare team as they emerge. Conclusions: Expert nurses have played an advanced role in the management of care and human resources by exercising effective leadership in the clinical setting. Care has been hampered due to the crisis, which causes nurses moral distress because they have been unable to meet standards of quality and excellence in care.

Obstacles to compassion-giving among nursing and midwifery managers: an international study.

AIM: To explore nursing and midwifery managers' views regarding obstacles to compassion-giving across country cultures. BACKGROUND: The benefit of compassionate leadership is being advocated, but despite the fact that health care is invariably conducted within culturally diverse workplaces, the interconnection of culture, compassion and leadership is rarely addressed. Furthermore, evidence on how cultural factors hinder the expression of compassion among nursing and midwifery managers is lacking. METHODS: Cross-sectional, exploratory, international online survey involving 1 217 participants from 17 countries. Managers' responses on open-ended questions related to barriers for providing compassion were entered and thematically analysed through NVivo. RESULTS: Three key themes related to compassion-giving obstacles emerged across countries: 1. related to the managers' personal characteristics and experiences; 2. system-related; and 3. staff-related. CONCLUSIONS: Obstacles to compassion-giving among managers vary across countries. An understanding of the variations across countries and cultures of what impedes compassion to flourish in health care is important. IMPLICATIONS FOR NURSING PRACTICE AND POLICY: Nursing mangers should wisely use their power by adopting leadership styles that promote culturally competent and compassionate workplaces with respect for human rights. Policymakers should identify training and mentoring needs to enable the development of managers' practical wisdom. Appropriate national and international policies should facilitate the establishment of standards and guidelines for compassionate leadership, in the face of distorted organizational cultures and system-related obstacles to compassion-giving.

[Therapeutic restraint management in Intensive Care Units: Phenomenological approach to nursing reality]. / Manejo de la inmovilización terapéutica en Unidades de Cuidados Críticos: aproximación fenomenológica a la realidad enfermera.

AIMS: To identify nursing experience on physical restraint management in Critical Care Units. To analyse similarities and differences in nursing experience on physical restraint management according to the clinical context that they are involved in. METHOD: A multicentre phenomenological study was carried out including 14 Critical Care Units in Madrid, classified according to physical restraint use: Common/systematic use, lacking/personalised use, and mixed use. Five focus groups (23 participants were selected following purposeful sampling) were convened, concluding in data saturation. Data analysis was focused on thematic content analysis following Colaizzi's method. FINDINGS: Six main themes: Physical restraint meaning in Critical Care Units, safety (self-retreat vital devices), contribution factors, feelings, alternatives, and pending issues. Although some themes are common to the 3 Critical Care Unit types, discourse differences are found as regards to indication, feelings, systematic use of pain and sedation measurement tools. CONCLUSIONS: In order to achieve real physical restraint reduction in Critical Care Units, it is necessary to have a deep understanding of restraints use in the specific clinical context. As self-retreat vital devices emerge as central concept, some interventions proposed in other settings could not be effective, requiring alternatives for critical care patients. Discourse variations laid out in the different Critical Care Unit types could highlight key items that determine the use and different attitudes towards physical restraint.

The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study.

OBJECTIVES: To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement. METHOD: Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals). RESULTS: A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = -.431) and in the subgroup of patients with ETT (r = -.521). CONCLUSIONS: Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.

The value of human resources: Experience of critical care nurses during the COVID-19 epidemic.

The COVID-19 pandemic has caused an unprecedented health crisis. Pressure on the National Health System has created unique demand particularly in certain services and care units like the critical care units. OBJECTIVE: To learn about the experience of nurses in caring for people with coronavirus in critical care units. METHOD: A qualitative phenomenological study that constitutes the second phase of a mixed methodology project. We conducted interviews with 17 nurses caring for patients affected by COVID-19 in critical care units. The interviews were audio-recorded, transcribed, and analysed using thematic discourse analysis. RESULTS: This article shows the findings around the theme "the value of human resources" which is nuanced through sub-themes "it's not the beds, it's the expert staff", "shouldering the patient's burden", and suffering because "they have not cared well". DISCUSSION: Expert nurses have emerged as leading professionals in the care of the critical patient during the COVID-19 pandemic. This leadership is executed from a profile framed in an inclusive philosophy where wisdom, agility and intuition are the key elements underpinning problem identification and solving in a creative way, while adapting to the needs of the patient and healthcare team as they emerge. CONCLUSIONS: Expert nurses have played an advanced role in the management of care and human resources by exercising effective leadership in the clinical setting. Care has been hampered due to the crisis, which causes nurses moral distress because they have been unable to meet standards of quality and excellence in care.

Children's visits to the paediatric intensive care unit from the nurses' experience.

BACKGROUND: Family process disruption is one of the main consequences of the hospitalization of a critically ill child in a Paediatric Intensive Care Unit (PICU). Children's visits to PICU may help improve family coping. However, this is not standard practice and nurses' experiences in facilitating children's visits to units where it is encouraged is unknown. AIM: To explore nurses' experience related to promoting the visits of siblings to PICU. METHODS: An interpretative phenomenological study was carried out through in-depth interviews in two PICUs belonging to third level public hospitals in Madrid. Twelve nurses with more than two years of experience in PICU were interviewed. They were all were working in PICU during the study. Furthermore, a PICU psychologist with an experience of four years was interviewed and this was considered shadowed data. Data analysis followed a thematic discourse analysis. RESULTS: Nurses' experience of facilitating children's visits to PICU can be condensed into four themes: emerging demand for visits, progressive preparation, decision-making through common consensus and creating intimate spaces. CONCLUSIONS: The experience of nurses in facilitating visits is mainly in response to the demand of families going through prolonged hospitalisation or end-of-life situations. The role of the nurse is one of accompaniment, recognising the major role of parents in the preparation of children and in developing the visit. Nurses feel insecure and lack resources for emotional support and demand action protocols to guide intervention and decision making.

[Phosphorus binders: preferences of patients on haemodialysis and its impact on treatment compliance and phosphorus control]. / Captores del fósforo: preferencias de los pacientes en hemodiálisis y su repercusión sobre el cumplimiento del tratamiento y el control del fósforo.

INTRODUCTION: Non-adherence to phosphate binding (PB) medication may play a role in the difficulty in achieving the targets for phosphorus. We have a wide armamentarium of PB but preferences of patients are poorly understood. OBJECTIVE: to study the patients' preferences and beliefs regarding PB and their influence on adherence and serum phosphate. METHODS: A cross-sectional cohort study was performed. A total of 121 hemodialysis patients answered a specific questionnaire in which they were questioned about adherence, the type of PB they preferred and the reasons for their choice. All patients questioned tasted two or three PB. The consequence of non-adherence to PB was estimated indirectly by determination of serum phosphorus. RESULTS: Specific noncompliance with PB medication was recognized by 21.4% of patients. Patients non-adherent specifically to PB were more likely to have P levels >5.5 mg/dl (χ(2): 4.7; 95% CI 1.07-6.5; p = 0.03). Paradoxically, patients non-adherent showed greater knowledge of the use (χ(2): 17.3; 95% CI -2.2-10.1; p <0.0001) and importance of the drug (χ(2): 10.4; 95% CI -1.5-6.6; p = 0.001). The percentage of patients prescribed binders they did not like was 54.5%. Patients who were taking PB they did not like had a greater risk of having P levels >5.5 mg/dl) (χ(2): 13.3; 95% CI -1.1-1.5; p = 0.0001). Calcium acetate was the preferred PB in 47.1% of patients, lanthanum carbonate in 40%, sevelamer in 20.6% and aluminum hydroxide in 19.4%. The reasons claimed by patients for their negative ratings of PB were the type of dosage form, the taste, the number of tablets and gastric intolerance. Gastric intolerance and bad taste were more frequent in aluminum hydroxide patients (19.4% and 22.2%, respectively). Sevelamer received complaints about its dosage form because the tablets were too large and a large number of tablets were required (27.2%). 17.7% of patient who were taking lanthanum carbonate did not like the chewable tablets. CONCLUSION: patients who were taking binders that they did not like had worse serum P levels and were prescribed higher doses of binders. Knowing patients' preferences about the drugs prescribed may be a key factor in achieving adequate adherence to treatment.

360-Degree evaluation: Towards a comprehensive, integrated assessment of performance on clinical placement in nursing degrees: A descriptive observational study.

BACKGROUND: The assessment of the acquisition of clinical competencies is a critical issue for nursing students. 360-degree evaluations are a widespread practice in professional competency assessment and can be applied to the learning/teaching process of future nurses. OBJECTIVES: To determine the effectiveness of the implementation of a 360-degree evaluation proposal for assessing the competencies acquired by third-year nursing students during their clinical placements. DESIGN: A mixed-methods design was used with a primary component (a cross-sectional descriptive observational design) and a parallel qualitative component. PARTICIPANTS: Sixty-seven third-year nursing students from a public university in Madrid, Spain, who were undertaking their clinical placements during seven weeks in medical/surgical units in hospital settings. METHODS: This study was conducted between September 2017 and May 2018. Quantitative data were obtained using assessment tools specifically developed for this 360-degree evaluation proposal. Qualitative information was collected from two focus groups, one with students and one with teaching staff. A descriptive analysis of the quantitative data was conducted. Qualitative data were studied using a thematic analysis. RESULTS: The mean scores for each of the items in the 360-degree evaluation were high, with the highest grades being observed in the evaluations made by peers and patients (a mean of 9.1 out of 10.0). On average, the 360-degree evaluation method yielded grades 0.067 percentage points higher than did the previous evaluation method (p ≤ 0.001). Students and teaching staff encountered difficulties in the evaluations made by users/families and other members of the healthcare team (nursing assistants and physicians), although they rated the overall proposal as being very powerful in terms of educational value. CONCLUSIONS: The 360-degree evaluation method is an innovative, motivating, and integrating approach to the acquisition of competencies with a focus on excellence.

Physical restraint in critical care units from the experience of doctors and nursing assistants: In search of an interdisciplinary interpretation. / La contención mecánica en unidades de cuidados críticos desde la experiencia de los médicos y técnicos en cuidados auxiliares de enfermería: buscando una lectura interdisciplinar.

OBJECTIVES: The study aim was to explore the experience of doctors and nursing assistants in the management of physical restraint (PR) in critical care units. METHOD: A multicentre phenomenological study that included 14 critical care units (CCU) in Madrid (Spain). The CCU were stratified according to their use of physical restraint: "frequently used" versus "seldom used". Three focus groups were formed: the first comprised nursing assistants from CCUs that frequently used physical restraint, the second comprised nursing assistants from CCUs that seldom used physical constraint, and the final group comprised doctors from both CCU subtypes. Sampling method: purposive. DATA ANALYSIS: thematic content analysis. Data saturation was achieved. RESULTS: Four principle themes emerged: 1) concept of safety and risk (patient safety versus the safety of the professional), 2) types of restraint, 3) professional responsibilities (prescription, recording, and professional roles) and 4) "zero restraint" paradigm. The conceptualisation regarding the use of physical contentions shows differences in some of the principal themes, depending on the type of CCU, in terms of policies, use and management of physical constraint (frequently used versus seldom used). CONCLUSIONS: The real reduction in the use of physical restraint in CCU must be based on one crucial point: acceptance of the complexity of the phenomenon. The use of physical restraint observed in the different CCU is influenced by individual, group and organisational factors. These factors will determine how doctors and nursing assistants interpret safety and risk, the centre of care (patient or professional-centred care), the concept of restraint, professional responsibilities and interventions, interactions of the team and the leadership.

A case of endocarditis of difficult diagnosis in dialysis: could "pest" friends be involved?

We report a case of A. xylosoxidans endocarditis of larvate clinical presentation in a central venous catheter-dependent hemodialysis patient of difficult diagnosis and poor evolution despite a high index of suspicion and consequent assessment. A 50-year-old man on hemodialysis presented with inflammatory-malnutrition parameters during the months prior to diagnosis of endocarditis, whilst he was otherwise asymptomatic. No vegetations were detectable on his cardiac valves at repeated echocardiography until third transesophageal echocardiography was performed, and confirmed intraoperatively. On the occasion of positive peripheral blood culture for Alcaligenes (Achromobacter) xylosoxidans, the etiological diagnosis was retrospectively explained given his history of animal exposure - hunting rabbits using his pet ferrets. This bacterium is an emergent and resistant organism, mostly related to nosocomial infections and environmental water sources. Reservoirs include the microflora of the nasal cavity of rabbits and the dentogingival sulcus of ferrets. We presume that A. xylosoxidans endocarditis was transmitted from the patient's pets. It highlights the importance of early recognition of an inflammatory status and investigation of the underlying cause. Additionally, the causative bacterium emphasizes the importance of registering exposure to animals in CVC-dependent patients as well as the need for their awareness of hygienic precautions and the infectious risk associated to catheters.

Nephrotic syndrome as paraneoplastic manifestation of a primary pulmonary lymphoepithelioma-like carcinoma.

We present a case of nephrotic syndrome secondary to a membranous glomerulonephritis (MG), in a nonsmoking female with a solitary pulmonary nodule, which did not show growth during 2 years of followup. A biopsy by videothoracoscopy showed a granulomatous non-neoplastic process with giant multinucleated cells. The appearance of a nephrotic syndrome and its interpretation as paraneoplastic revealed the existence of a primary pulmonary lymphoepithelioma-like carcinoma (LELC), a very rare pulmonary tumor. After resection of tumor there was a complete recovery from the nephrotic syndrome. This case highlights how the investigation of paraneoplastic syndromes can help in the early diagnosis of some malignancies.

[Superficialization of autologous vascular access: an alternative to the use of vascular prostheses and permanent catheters]. / Superficialización de accesos venosos autólogos: una alternativa al uso de prótesis vasculares y catéteres permanentes.

INTRODUCTION: We review our experience with autologous veins Superficialization (Spf), to establish the actual possibilities of this kind of vascular access in our area. METHODS: Between January/2001 and January/2008, Spf was performed in 48 patients. Mean follow-up time was 18.8 (0.2-75.7) months. Primary failure rate was recorded; primary and secondary survival were estimated using the Kaplan-Meier method; and its possible associations with several variables were analyzed. RESULTS: the maturity rate was 97.9%; and the rate of primary failure 2.0%. After Spf, mean time of primary and secondary survival were 65 months and 67 months, respectively. Four vascular thromboses were observed. None of the presurgery variables analyzed (age; sex; diabetes mellitus; ipsilateral central catheter; the number of previous VA attempts; and obesity) were significantly associated with maturity rate, primary or secondary survivals. CONCLUSION: the Spf can be a good option alternative to the use of prosthetic grafts or permanent central vascular catheters.

[Operation to remove tunnelled venous catheters in a dialysis unit. Is it possible to reverse the trend in their growing use?]. / Operación retirada de catéteres venosos tunelizados en una unidad de diálisis. ¿Es posible cambiar la tendencia en el uso creciente de éstos?

INTRODUCTION: Introduction In an attempt to reduce unnecessary central venous catheters (CVC) dependence in prevalent population, a "CVC removal" programme was initiated in our unit. The objective was to diminish the number of CVC and to analyze the causes of their insertion and maintenance. On 09/01/07, 38 out of 173 prevalent patients on hemodialysis. Methods were CVC dependant (21.9%): 16 incident patients (42,1%) and 22 (57,8%) prevalent patients. All of them were re-evaluated for permanent vascular access utilization, included those previously rejected for surgery. Physical, psychical and vascular aspects regarding each patient were taken into consideration. The following variables were age, Body mass index, time on hemodialysis, Charlson analyzed comorbidity index, DM or vascular comorbidities and number of vascular accesses created prior to CVC placement. In those patients in whom AVF creation was feasible, the following were registered after 18 months of 1.Primary failure rate. 2. Related complications. 3. up follow Percentage of usable AVF or AVG. 4. Percentage of removed CVC. 5. Mortality and hospitalization. The decision of no realization of a new vascular access and? Results maintenance of TVC was performed in 21 patients (55.2%). In 9 of them was decision of the nephrologists and the family. In 11 patients was decision of vascular surgeon due to vascular bed exhaustion. A permanent VA was achieved in 17 patients (44.7%), 50% of them was incident patients and 45% prevalent patients. The primary failure rate was 0%. The TVC was withdrawn in 11/17 (64.7%). Only 4 patients remain without TVC after 18 months of follow-up: 5 patients died (4 with a AVF functioning and 1 VA closure due to steal syndrome) and in 8 patients was mandatory to reintroduce the TVC again. Immediate complications after the surgery were: 1 severe haematoma, 2 infections and 2 severe sequestrations. 3 patients required hospital admission following complications directly related to VA. Mean time of free of TVC was 5.2 months (range: 0.7- 14.3 months). The mortality was 29,4% (5/17) in the group of patients with a new VA and 9,5% (2/21) in the other group(RR 3,19; IC 95%: 0,68-13,98; p: 0,11). No significant differences were observed between patients who transitioned to a permanent vascular access and those who remained TVC dependant in regards to age, gender, BMI, time on dialysis, DM, comorbidity or number of previous VA, Transition from CVC use to hospitalizations or mortality. Conclusions permanent vascular access is possible in prevalent patients in dialysis. Improvement was achieved by a modest amount, and after a prolonged process with gravel complications, some of which proved severe. Need for CVC dependence is confirmed in a high percentage of prevalent patients on dialysis. Comorbidity might have influenced the results. The quality standard should be adequate to reality of current population on hemodialysis.

Management of calcific uremic arteriolopathy (calciphylaxis) with a combination of treatments, including hyperbaric oxygen therapy.

Calcific uremic arteriolopathy (CUA) is a rare but serious complication of end-stage renal disease presenting as painful cutaneous lesions and progressing to non-healing ulcers and gangrene. This syndrome is associated with calcium and phosphorus deposits within small arteries of the skin. The pathognomonic lesion is vascular calcification with intimal arterial hypertrophy and superimposed small-vessel thrombosis. The condition is being increasingly recognized and reported as a contributing factor to death in dialysis patients, with secondary infection and sepsis as the major cause of mortality. No standard treatment has been established for this syndrome. We present the therapeutic approach employed in two patients, which successfully resulted in healing of the lesions, using a combination of measures to control the factors potentially related to development of CUA and hyperbaric oxygen therapy.

[Can we improve our results in hemodialysis? Setting quality objectives, feedback, and benchmarking]. / Es posible mejorar nuestros resultados en hemodiálisis? Establecimiento de objetivos de calidad, retroalimentación (Feedback) y benchmarking.

UNLABELLED: To diminish inter centres variability in applied medical treatments, as well as in the results obtained with them, is one of the main challenges that Nephrology faces now a days. The systematic and planned use of Clinical Performance Measures (CPMs), Feedback and Benchmarking are tools that can help clinicians to reach such an objective. In this study we evaluate the consequences of applying those techniques in the results obtained in three haemodialysis units. METHODS: we analyzed the results obtained in 311 patients dialyzed in the three units during the period 2006-2007. Established and evaluated objectives were as follows: 1.- To increase the percentage of patients with a serum calcium below 9,5 mg/dl over 70%; 2.- To increase the percentage of patients with a serum phosphorus under 5,5 mg/dl over 80%; 3.- To increase the percentage of patients with a serum PTH in between 150-300 pg/ml over 40%; 4.- To diminish the percentage of patients with a serum ferritine below 100 ng/ml under 10%, in one of the units that at the beginning of the study was not accomplishing that objective. Every three months each unit received their own results as well as the results of the two other units. RESULTS: the percentage of patients with serum calcium below 9,5 mg/dl increased significantly in the three units (54,6%, 56,1% and 55,6% at the beginning; 87,7%, 82.9% and 75,1% at the end of the study, respectively; p<0,001). The same was observed for the percentage of patients with a serum phosphorus below 5,5 mg/dl (77,9%, 73,6% and 66,0% at the beginning; 81,7%, 78,0% and 85.9% at the end, respectively; p: not significant), and for the percentage of patients with PTH between 150-300 pg/ml (32,9%, 43,1% and 26,4% versus 47,5%, 41,4% and 39.5%, respectively; p: not significant). The percentage of patients with a serum ferritin below 100 ng/ml in unit B diminished from 30% to 5,3% (p<0,001), reaching results similar the the two other units. Mean erythropoietin (EPO) consumption during the year 2005 was 145,5+/-13,2 U/kg/week in unit A; 226,2+/-39,8 U/kg/week in unit B, and 175,5+/-13,9 U/kg/week in unit C. At the end of year 2007, mean EPO consumption was significantly lower in unit B (144,2+/-15 U/kg/week), and similar to the other two units (140+/-14,2 in unit A and 135,1+/-13,8 in unit C). CONCLUSION: The results of this study permit to conclude that the use of QPM's and quality targets, combined with feedback and benchmarking, allows for the improvement of clinical results. Each centre should establish their own objectives, independently of the defined quality standards, so as to reach such standards or even to improve them. In this study, the three units showed a general improvement in their results, tending towards similar outcomes for the same clinical processes.

[Is Cinacalcet a cost-effective treatment in severe secondary hyperparathyroidism in patients on hemodialysis?]. / Es el cinacalcet un tratamiento coste-efectivo en el hiperparatiroidismo secundario severo en pacientes en hemodiálisis?

BACKGROUND: A previous study using cinacalcet, as compared to vitamin D alone, showed a better reduction response of PTH levels and a significant diminution of secondary effects. The objective of present study was to evaluate the additional cost of adding cinacalcet to the standard treatment of patients with severe secondary hyperparathyroidism (SHPT) taking into account the treatment goals achieved. METHODS: 12 month prospective study of 23 patients with severe SHPT. Two treatment regimens were considered: standard treatment (m 0) and standard treatment plus cinacalcet (m 12). Four consequences of inadequate control of SHPT were registered: parathiroid hormone (PTH), Calcium (Ca), Phosphorus (P) and the Ca x P product serum levels. Treatment effectiveness was measured as percentage of patients who achieved treatment goal according to each indicator: PTH < 800 pg/mL, PTH between 150 and 300 pg/mL, Calcium < 9.5 mg/dL, Phosphorus < 5.5 mg/dL, and Ca x P product < 55. Annual and monthly costs were calculated for both treatment regimens using Spanish 2007 tariffs, and taking into account the dose reduction in some other treatments. Results are presented as incremental costs and cost per patient who achieved treatment goal. RESULTS: At 12 month it was observed a higher percentage of patients who achieved simultaneously the 4 therapeutic goals with respect to basal moment, from 0% to 52.1%. Cinacalcet allowed to save costs in concomitant drugs, achieving a total saving of 149 euros per patient and month. At 12 month, Cinacalcet achieved a reduction of percentage of patients with PTH > 800 pgr/mL with half of costs than standard treatment (651.35 euros vs 1363.68 euros). It was not possible to calculate the cost for PTH indicator since at the study onset, there was no patient who achieved a level between 150 and 300 pg/mL. Cinacalcet allowed reaching treatment goals in Calcium, Phosphorus and Ca x P product in a more cost-effective way (2164.2 euros vs 2684.8 euros). CONCLUSIONS: Although Cinacalcet is expensive,p atients treated with Cinacalcet showed a minor cost per patient who achieved treatment goal than patients without Cinacalcet. The ability of cinacalcet to reduce PTH secretion, along with the reductions in the serum Ca, P, and Ca x P product, provides an alternative to the traditional treatment paradigm, and should be a welcomed addition in the management of SHPT.

[Changes in vascular access in a dialysis unit in recent years: planning problems, change in preferences, or demographic change?]. / Cambios en el acceso vascular en una unidad de diálisis en los últimos años: problemas de planificación, cambio de preferencias o cambio demográfico?

BACKGROUND: Evidence on the reasons for the general and discouraging overutilization of catheters in DOPPS countries is lacking. METHODS: We analysed the changes in distribution of the different types of vascular access in all 398 patients ongoing hemodialysis at our unit, from January 2000 until December 2005, as well as patients' characteristics. Secondly, risk factors associated with the use of permanent catheters were evaluated in all 95 patients who used that kind of vascular access from January 1997 until April 2006. RESULTS: The percentage of fistulas in prevalent patients diminished from year 2000 until year 2005 (from 95% to 77.9%); concurrently there was an increase in the use of permanent catheters (from 4.2% to 21.5%). The percentage of incident patients having a usable fistula or graft at the beginning of hemodialysis diminished progressively (83.4% in 2000; 69.3% in 2005), and there was a significant increase in the percentage of incident patients using a permanent catheter (from 0 to 23%). Coincidentally, there was a change in patients characteristics: increasing age (71.3 vs. 60.5 years); greater diabetes percentage (7.1% vs. 18.5%) and less time on dialysis (93.2 vs 37 months; p < 0.03). Causes of permanent catheter insertion varied, exhaustion of all other arteriovenous options being the most frequent in the first period of the study and the presence of an unsuitable vascular anatomy in the second. CONCLUSIONS: Despite our policy favoring arteriovenous angioaccess, our results with regards to vascular access worsened in both prevalent and incident patients, coinciding with a change in patients' characteristics. We believe that reversing this trend may become more complicated as the population on dialysis grows older and becomes more prone to diabetes.

[Use of the aluminum phosphate-binders in hemodialysis in the ultrapure water era]. / Uso de captores alumínicos en hemodiálisis en la era del agua ultrapura.

INTRODUCTION: Aluminium binder has been ill-advised, but his use remain applicable in the clinique practice in very seleccionated and particular patients. The repercussion of prolonged treatment with low doses of aluminium phosphate-binders in haemodialysis was studied. The haemodialysis unit had a double osmosis inverse and the aluminium levels in haemodialysis liquid was less than 2 micrograms/liter. METHODS: 41 patients of the 295 on haemodialysis received aluminium phosphate-binders since the 2005 January to the 2007 November. The mean time of treatment was 17.8 months, and the doses was 3.9 tablets day (mean of 463 grams in the studied period). The association of low doses of aluminium phosphate-binders permitted a better control of phosphorus (6.8 to 4.8 mg/dl; p<0.0001), with a reduction of the others phosphate-binders: sevelamer (10.4 a 8 tablets/day; p<0.0001) and calcium phosphate-binders (4.6 to 3.1 tablets/day; p<0.0001). The serum aluminium increased after the aluminium treatment (6.8 to 13.8 mcg/l; p<0.0001), and no toxicity indirect signs were observed on CMV, haemoglobin, none PTH. Five patients (12.1%) reached aluminium serum levels higher 20 mcg/l, and none reached the 40 mcg/l. CONCLUSIONS: The aluminium phosphate-binders were effective, economical and, now, with an apparent better security profile than in a previous time, but it is very important to be careful with this use and to follow a vigilance strict on patients and haemodialysis liquid.

[Adverse reactions to polysulphone membrane dialyzers durind hemodialysis]. / Efectos adversos a polisulfona durante la sesión de hemodiálisis.

The majority of severe hypersensitivity reactions in hemodialysis (HD) patients has been due to sensitization to ethylene oxide or to non-biocompatible membrane dialyzers like cupramonium membrane. However could be the possibility of adverse reactions with other hemodialysis substances. Adverse reactions with biocompatible polisulphone membranes are not frequent, but some authors described anaphilactoid reactions related to them. Any severe clinical syndrome of broncoespasm during hemodialysis with several biocompatible polysulphone membranes made by different manufacturers and with a variety of sterilization methods is presented here. The following day he was dialyzed on an cellulose triacetate dialyzer and the hemodialysis treatment was uneventful. This cas report demonstrates the complex nature involving a hypersensitivity reaction to HD.