Persistencia de tratamiento con antagonistas del factor de necrosis tumoral frente a antagonistas de interleucinas en psoriasis moderada-grave / Persistence of treatment with tumor necrosis factor antagonists versus interleukin antagonists in moderate-severe psoriasis

Objetivo: Evaluar y comparar el tiempo de persistencia y analizar los motivos de suspensión con fármacos antagonistas del factor de necrosis tumoral (anti-TNF) frente a antagonistas de interleucinas (anti-IL) en primera línea de tratamiento biológico en pacientes con psoriasis.Material y métodos: Estudio retrospectivo observacional realizado entre 01/2010 y 05/2019. Se incluyeron pacientes adultos diagnosticados de psoriasis moderada-grave en tratamiento con anti-TNF o anti-IL en primera línea de tratamiento biológico. Se estudiaron variables demográficas y relacionadas con el tratamiento, calculándose el tiempo de persistencia con el fármaco de estudio, así como las suspensiones de tratamiento. Resultados: Se incluyeron 94 pacientes (39 mujeres) con una media de 49 años (desviación estándar 13,0), 46 (48,9%) pacientes tratados con anti-TNF (35/46 adalimumab y 11/46 etanercept) y 48 (51,1%) pacientes tratados con anti-IL (26/48 secukinumab, 15/48 ustekinumab y 7/48 ixekizumab). El tiempo de persistencia en primera línea de tratamiento biológico fue de 18,4 (rango intercuartílico (RIQ) 22,2) meses, siendo 9,3 (RIQ 21,7) meses superior en los pacientes tratados con anti-IL (24,7 vs. 15,4 meses; p=0,002). A la finalización del seguimiento el 38,3% (36/94) de la población había interrumpido el tratamiento, debido a: falta de efectividad (34,8% (16/46) anti-TNF vs. 14,6% (7/48) anti-IL; p=0,003), eventos adversos (2,2% (1/46) anti-TNF) y otros motivos (17,4% (8/46) anti-TNF vs. 8,3% (4/48) con anti-IL; p>0,05). Conclusiones: El tiempo de persistencia en primera línea de tratamiento biológico fue de 18,4 meses, siendo significativamente superior en los pacientes tratados con anti-IL. El principal motivo de suspensión fue la falta de efectividad en ambos grupos de tratamiento. (AU)

Objective: To evaluate and compare the time of persistence and to analyse the discontinuation reasons with tumor necrosis factor antagonists (anti-TNF) vs. interleukin antagonists (anti-IL) as first line with biological treatments in patients with psoriasis. Material and methods: Retrospective observational study carried out between 01/2010 and 05/2019. Adult patients diagnosed with moderate to severe psoriasis in treatment with anti-TNF or anti-IL as first line with biological treatments were included. Demographic and treatment-related variables were studied, calculating the time of persistence with the study drug, as well as treatment discontinuations. Results: We included 94 patients (39 women) with a mean of 49 years (standard deviation 13.0), 46 (48.9%) patients treated with anti-TNF (35/46 adalimumab and 11/46 etanercept) and 48 (51.1%) patients treated with anti-IL (26/48 secukinumab, 15/48 ustekinumab and 7/48 ixekizumab). Persistence time with biological treatment in first line was 18.4 (interquartile range (IQR) 22.2) months, being 9.3 (IQR 21.7) months higher in patients treated with anti-IL (24.7 vs. 15.4 months; p=0.002). At the end of the follow-up, 38.3% (36/94) of the population had discontinued their treatments. The reasons for discontinuation were: lack of effectiveness (34.8% (16/46) anti-TNF vs. 14.6% (7/48) anti-IL; p=0.003), side effects (2.2% (1/46) anti-TNF) and other reasons (17.4% (8/46) anti-TNF vs. 8.3% (4/48) anti-IL; p>0.05). Conclusion: The persistence time with biological treatment in first line was 18.4 months, being significantly higher in the anti-IL group. The main reason of discontinuation was lack of effectiveness in both groups of treatment. (AU)

[Organization and management of nutritional care process in hospitalized patients: the model implemented in the "Hospital Universitario de La Ribera"]. / Organización y funcionamiento de la atención nutricional hospitalaria: el modelo implantado en el Hospital Universitario de La Ribera.

INTRODUCTION: Hospital malnutrition shows a high prevalence and is an indicator of poor quality care. The intervention of different professionals involved in the nutritional care process performing uncoordinated and with different criteria is one of the reasons that contribute to perpetuate this situation. OBJECTIVE: To describe the model implemented in the "Hospital Universitario de la Ribera" for providing nutritional care to patients. METHOD: The model implemented in the "Hospital Universitario de la Ribera" is characterized by the coordinated intervention of the health professionals performing with the common goal of providing patients' nutritional care. The nutrition plan is carried out comprehensively from malnutrition identification to the establishment of the nutrition plan and monitoring as well as its adaptation to the patient's progress and discharge recommendations. The key elements to achieve this goal are described: the Nutrition Department and the Pharmacy Department, the information system available that allows to share and exchange information effectively and a dynamic and interdisciplinary Commission of Nutrition and Dietetics. CONCLUSION: At the "Hospital Universitario de la Ribera" an organization that ensures continuity of care throughout the nutritional process and its connection with primary health care has been established.

Organización y funcionamiento de la atención nutricional hospitalaria; el modelo implantado en el Hospital Universitario de La Ribera / Organization and management of nutritional care process in hospitalized patients; the model implemented in the 'Hospital Universitario de La Ribera'

Introducción: La malnutrición hospitalaria manifiesta una elevada prevalencia y es un indicador de baja calidad asistencial. Entre los motivos que perpetuán esta situación se identifican procesos asistenciales que se realizan por diferentes profesionales con criterios de actuación divergentes y a través de intervenciones fragmentadas. Objetivo: Describir el modelo implantado en el Hospital Universitario de la Ribera para proporcionar atención nutricional. Método: El modelo implementado en el Hospital Universitario de la Ribera tiene como característica diferencial la intervención coordinada de los profesionales que participan en el proceso nutricional con el objetivo de que la atención nutricional se lleve a cabo de forma integral, desde la identificación de la malnutrición, el establecimiento y monitorización del plan nutricional y su adaptación a la evolución del paciente y recomendaciones al alta. Se describen los elementos de estructura para la consecución de este objetivo: el Servicio de Nutrición y Servicio de Farmacia, el sistema de información que permite compartir e intercambiar información de forma efectiva y el funcionamiento resolutivo de la Comisión de Nutrición y Dietética interdisciplinar. Conclusión: En el Hospital Universitario de la Ribera se ha establecido una organización que garantiza la continuidad asistencial a lo largo del proceso nutricional y su conexión con atención primaria de salud (AU)

Introduction: Hospital malnutrition shows a high prevalence and is an indicator of poor quality care. The intervention of different professionals involved in the nutritional care process performing uncoordinated and with different criteria is one of the reasons that contribute to perpetuate this situation. Objective: To describe the model implemented in the ‘Hospital Universitario de la Ribera’ for providing nutritional care to patients. Method: The model implemented in the ‘Hospital Universitario de la Ribera’ is characterized by the coordinated intervention of the health professionals performing with the common goal of providing patients' nutritional care. The nutrition plan is carried out comprehensively from malnutrition identification to the establishment of the nutrition plan and monitoring as well as its adaptation to the patient's progress and discharge recommendations. The key elements to achieve this goal are described: the Nutrition Department and the Pharmacy Department, the information system available that allows to share and exchange information effectively and a dynamic and interdisciplinary Commission of Nutrition and Dietetics. Conclusion: At the ‘Hospital Universitario de la Ribera’ an organization that ensures continuity of care throughout the nutritional process and its connection with primary health care has been established (AU)

Population pharmacokinetic parameters of vancomycin in critically ill patients.

BACKGROUND: Intensive care unit patients are a highly heterogeneous population. Accurate dosing for this population requires characterization of the appropriate pharmacokinetic parameters. OBJECTIVE: To estimate population pharmacokinetic parameters of vancomycin (VAN) in adult critically ill patients and to establish the predictive performance of the resulting model. PATIENTS AND METHOD: Fifty critically ill patients with suspected or documented infection with VAN-sensitive micro-organisms were included. Thirty patients and 234 serum concentration-time sets obtained during clinical routine monitoring were used to estimate the pharmacokinetic parameters (group A). An open bicompartimental model with intermittent intravenous administration was used to adjust the data. Data were evaluated using a nonlinear mixed effects model (nonmem software). Forty plasma concentration-time data sets from 20 patients were used for validation using the Bayesian method (group B). RESULTS: There was a linear relationship between creatinine clearance (Cl(cr)) and VAN clearance (Cl(VAN)). The inclusion of the non-renal clearance (Cl(nr)) (intercept of Cl(VAN) vs. Cl(cr) relationship) improved the model significantly (Cl(nr) 17 mL/min). The volume of distribution seems to be larger than previously reported: volume of the central compartment (V(c)) was 0.41 L/kg and volume of the peripheral compartment was (V(p)), 1.32 L/kg. The mean error (bias) and mean absolute error (precision) for predicting subsequent peak concentrations were -2.16 and 9.28 mg/L and for trough concentrations, -0.22 and 3.87 mg/L respectively. CONCLUSION: The use of population-specific pharmacokinetic parameters and Bayesian forecasting improves dosage-regimen design.

[Integral computerization of health care for inpatients. Impact on primary care activities]. / Informatización integral de la asistencia sanitaria en el paciente hospitalizado. Repercusión sobre las actividades de atención farmacéutica.

INTRODUCTION: Due to its iatrogenic potential and economic impact, drug prescription is one of the most complex tasks within the health care process. Electronic prescription systems (EPS), and particularly expert systems, increase quality by reducing errors in the prescribing and dispensing processes. Besides, electronic prescription reduces costs. On the other hand, it demands a new equilibrium in the delivery of pharmaceutical services. METHOD: The EPS established at "Hospital de la Ribera" is described. This system is basically characterised by: (1) its integration within the electronic global system throughout a computer network; (2) drugs are ordered directly by physicians in the electronic system; (3) pharmacists access the whole clinical record of patients "in situ"; (4) and integration of clinical activities by pharmacists in the patient medical record. The impact of this system on pharmaceutical care activities such as identification, reporting and documentation of drug-related problems (DRPs) versus traditional approaches is analysed. RESULTS: Access to patient information throughout the system facilitates DRP identification, with a resulting overall prevalence of clinically relevant drug-related problems of 9%. CONCLUSION: The model implemented in our hospital favours the development of clinical activities by pharmacists as it allows communication among health care professionals, activities are permanently recorded in patient medical charts, and a formal document of pharmacist involvement and compromise with the clinical progress and outcome of patients ensues.

Informatización integral de la asistencia sanitaria en el paciente hospitalizado. Repercusión sobre las actividades de atención farmacéutica / Integral computerization of health care for inpatients. Impact on primary care activities

Introducción: La prescripción de medicamentos es una de las tareas más complejas dentro del proceso asistencial, tanto por su potencial iatrogénico, como por su impacto económico. El desarrollo de los sistemas de prescripción informatizada (SPI), y en particular los sistemas expertos, supone una mejora en la calidad asistencial en la medida en que disminuyen los errores en la prescripción y dispensación al tiempo que reducen los costes. Por otra parte, su implantación motiva el establecimiento de un nuevo equilibrio en la provisión de los servicios farmacéuticos. Método: Se describe el sistema de prescripción electrónica establecido en el Hospital de la Ribera que se caracteriza por: a) formar parte del sistema informático integral del hospital; b) la prescripción la realiza directamente el médico en el sistema informático; c) dispone de acceso in situ a la totalidad de la historia clínica del paciente; y d) integra las actividades de atención farmacéutica en la historia clínica del paciente. Se analiza la repercusión del sistema sobre las actividades de atención farmacéutica de identificación, comunicación y documentación de problemas relacionados con los medicamentos (PRM) frente al sistema tradicional de revisión de la historia farmacoterapéutica. Resultado: El acceso a la información del paciente a través del sistema facilita la identificación de PRM, de manera que la prevalencia global de problemas relacionados con el medicamento con relevancia clínica se sitúa en el 9 por ciento. Conclusiones: El sistema descrito facilita la identificación de problemas relacionados con los medicamentos, la comunicación con el equipo asistencial y permite documentar las actividades de atención farmacéutica en la historia clínica del paciente. (AU)

Quality improvement in parenteral nutrition care.

The therapeutic objective of parenteral nutrition, as well as any other pharmacological treatment, must be organized for and focused on the patient, to obtain outcomes associated with an improvement in health status and quality of life. On this basis, the present article starts with a view of quality improvement in health care, identifying the structure, process and outcome paradigm for drug therapy and parenteral nutrition elements of quality assessment, as well as strategies for quality improvement will be described. A model of the organization assigned to parenteral nutrition care is proposed. In the future, computerized programs of parenteral nutrition may increase the risk of uncoordinated and fragmented care. The programs must improve health care of patient by exposing caregivers to the full alternatives of decisions with clinical and therapeutic data on patient individual.

High-dose methotrexate-doxycycline interaction.

OBJECTIVE: To report a case in which an interaction occurred between doxycycline and high-dose methotrexate (HD-MTX) and discuss its clinical, quality of life, and economic repercussions. CASE SUMMARY: A 17-year-old girl diagnosed with high-degree osteosarcoma in her left femur was admitted to our hospital to receive her eleventh postoperative cycle of HD-MTX, according to the clinical protocol approved at our hospital. Simultaneously, due to a palpebral abscess in her left eye, the patient received systemic treatment with doxycycline 100 mg every 12 hours. As in previous cycles, pharmacokinetic monitoring of methotrexate (MTX) plasma concentrations was performed to improve leucovorin calcium rescue. The biological half-life 12 and 24 hours after infusion showed that the patient was at high risk of intoxication. She then developed hematologic as well as gastrointestinal toxicity and remained hospitalized for 11 days. The patient was readmitted 48 hours after hospital discharge because of a febrile episode that required an additional hospital stay of 12 days, and the twelfth cycle of HD-MTX had to be postponed 18 days because of the results of the previous cycle. DISCUSSION: Significant differences (p < 0.05) were observed in the eleventh HD-MTX cycle for plasma concentrations and pharmacokinetic parameters compared with the previous 10 cycles. The interaction resulted in clinical, quality of life, and economic repercussions. CONCLUSIONS: The potential interaction between MTX and doxycycline may cause pharmacokinetic changes, and its clinical repercussions on the quality of life of the patient and associated costs should be considered.