Implementación de un programa basado en IPASS en UCI / Implementation of an IPASS-based program in the ICU

Introducción: El uso de herramientas estandarizadas como estrategia de comunicación para brindar información relevante, precisa y actualizada, forma parte de las iniciativas de calidad en las instituciones que cumplen altos estándares en la atención de pacientes. Objetivo: Describir la implementación de un programa de traspaso (IPASS) en unidades de cuidados intensivos pediátricos específicos. Material y métodos: Estudio cuasi-experimental antes y después de una intervención, no controlado, utilizando como sujetos a los profesionales de la salud involucrados en traspasos de pacientes de la unidad de terapia intensiva cardiovascular (UCI 35) e inmunosuprimidos (UCI 72). La intervención consistió en la introducción de un paquete de medidas de estandarización del traspaso de pacientes que consta de: una herramienta escrita, una mnemotecnia oral, una capacitación de trabajo en equipo, observación y devolución estandarizada de los traspasos, basados en la metodología IPASS. Se realizó además una encuesta de percepción de seguridad, tanto en la etapa pre y post intervención. Se comparó el cumplimiento de cada componente del traspaso antes y después de la intervención mediante la prueba de chi2 . Resultados: Se realizaron 101 observaciones de traspaso y 56 encuestas. La mediana de pacientes por cada observación fue 6 (r: 4 a 12) y el tiempo promedio de 26± 11 min. Conclusiones: El uso de un paquete de medidas de estandarización del traspaso de pacientes posquirúrgicos cardiovasculares e inmunosuprimidos aumentó significativamente la presencia de información clave sobre criticidad de la enfermedad, acciones y situaciones de contingencia, junto con la inclusión de la síntesis por el receptor del traspaso (AU)

Introduction: The use of standardized tools as a communication strategy to provide relevant, accurate, and up-to-date information is part of quality initiatives in institutions that adhere to high standards in patient care. Objective: To describe the implementation of a handoff program (IPASS) in specific pediatric intensive care units. Methods: An uncontrolled, quasi-experimental, beforeand-after study. Subjects were healthcare providers involved in patient handoffs in the cardiovascular (ICU 35) and immunocompromised-patient (ICU 72) intensive care units. The intervention consisted of the introduction of a bundle to standardize patient handoff consisting of: a written tool, an oral mnemonic, teamwork training, observation, and standardized feedback for handoffs based on the IPASS methodology. A safety perception survey was also carried out, both in the pre- and post-intervention stage. Compliance with each handoff component before and after the intervention was compared using the Chi-squared test. Results: 101 handoff observations and 56 surveys were conducted. The median number of patients per observation was 6 (r: 4 to 12) and the mean handoff time was 26±11 min. Conclusions: The use of a standardized handoff bundle for post-surgical cardiovascular and immunocompromised patients significantly increased the availability of key information on disease severity, actions, and contingency situations, as well as a synthesis by the handoff receiver (AU)

Integración de Un Sistema Robótico de Terapia Ocupacional para Extremidades Superiores con Estimulación Visual/Táctil de Los Pacientes / Integration of an Occupational-Therapy Robotic System for Upper Limbs with Visual/tactile Stimulation of Patients

Resumen: Los ejercicios tradicionales de rehabilitación de extremidades superiores tienen como objetivo principal recuperar la fuerza o rango de movimiento del área lesionada de los pacientes. Una opción alternativa que se ha presentado en los últimos años es el uso de interfaces hápticas, las cuales han mostrado ser herramientas potenciales en el apoyo de las terapias de rehabilitación. En este artículo se presenta un sistema de rehabilitación háptico de movimientos finos en extremidades superiores, cuya característica principal es que los usuarios del sistema pueden interactuar de forma visual y táctil con objetos virtuales mezclados con escenarios reales logrando con ello un ambiente de realidad aumentada. El sistema fue probado en dos etapas, ambas con sujetos que presentaban un grado de discapacidad en extremidades superiores. Los datos recopilados fueron trayectorias seguidas, errores de seguimiento y la actividad muscular obtenida por medio de electromiografía; esta información recolectada permitió analizar de forma cuantitativa el grado de avance de los pacientes. Además, se consideraron las valoraciones hechas por fisioterapeutas, concluyendo que el sistema propuesto puede ser utilizado como una herramienta viable que complementa a las terapias de rehabilitación convencionales.

Abstract: Traditional upper limb rehabilitation exercises are primarily aimed at regaining the strength or range of motion of the patients' injured area. An alternative option that has been presented in the last years is the use of haptic interfaces, which have shown their potential as tools that support rehabilitation therapies. This article presents a haptic system of rehabilitation for fine upper limb movements, whose main characteristic is that users of the system can interact in a visual and tactile fashion with virtual objects mixed with real scenarios, thereby achieving an augmented reality environment. The system was tested in two stages, both with subjects who had a degree of disability in upper limbs. The data collected were followed trajectories, follow-up errors and the muscular activity obtained by means of electromyography; the collected information enabled the analysis, in a quantitative way, of the degree of progress of the patients. In addition, the assessments made by physiotherapists were considered, concluding that the proposed system can be used as a viable complementary tool for conventional rehabilitation therapies.

Role of interspecies interactions in dual-species biofilms developed in vitro by uropathogens isolated from polymicrobial urinary catheter-associated bacteriuria.

Most catheter-associated urinary tract infections are polymicrobial. Here, uropathogen interactions in dual-species biofilms were studied. The dual-species associations selected based on their prevalence in clinical settings were Klebsiella pneumoniae-Escherichia coli, E. coli-Enterococcus faecalis, K. pneumoniae-E. faecalis, and K. pneumoniae-Proteus mirabilis. All species developed single-species biofilms in artificial urine. The ability of K. pneumoniae to form biofilms was not affected by E. coli or E. faecalis co-inoculation, but was impaired by P. mirabilis. Conversely, P. mirabilis established a biofilm when co-inoculated with K. pneumoniae. Additionally, E. coli persistence in biofilms was hampered by K. pneumoniae but not by E. faecalis. Interestingly, E. coli, but not K. pneumoniae, partially inhibited E. faecalis attachment to the surface and retarded biofilm development. The findings reveal bacterial interactions between uropathogens in dual-species biofilms ranged from affecting initial adhesion to outcompeting one bacterial species, depending on the identity of the partners involved.

Estudio comparativo de dos modos de ventilación no invasiva para retirar la asistencia respiratoria mecánica en lactantes post-operatorios de cirugía cardiovascular / Comparative study of two modalities of non-invasive ventilation for the weaning from mechanical ventilation of post-cardiovascular surgery infants

La mejor estrategia en el post-quirúrgico de cardiopatías congénitas para promover la extubación precoz y destete de asistencia respiratoria mecánica (ARM) con ventilación no invasiva (VNI) todavía no ha sido establecida. El objetivo es comparar eficacia de la presión positiva continua en la vía aérea (CPAP) vs presión positiva con dos niveles en la vía aérea (BIPAP) en la extubación electiva de estos pacientes. Es un estudio prospectivo entre el 1 de junio de 2008 y 31 marzo de 2010. Se randomizaron los pacientes para extubación electiva: modo CPAP o BIPAP. Se registraron datos demográficos y del procedimiento quirúrgico, entre otros. El fracaso de VNI fue definido como reintubación dentro de las 72 hs posteriores a la extubación o más de un criterio de intubación. Durante el periodo de estudio 1438 pacientes fueron admitidos en UCI35. En el grupo BIPAP se randomizaron 53 pacientes, de los cuales se extubaron exitosamente 49 (92%), pero 4 se reintubaron debido a falla cardiaca. En el grupo CPAP se randomizaron 46 y fallaron en la extubación 18 (39%) debido a múltiples episodios de desaturación y apneas. De éstos, 11 requirieron reintubación endotraqueal y ARM. En 7 pacientes, se pasó a modo BIPAP y permanecieron extubados, aunque el cruzamiento no fue parte del diseño de este estudio. En el destete de ARM de los pacientes post-quirúrgicos de cardiopatías congénitas, el uso de BIPAP fue más efectivo que CPAP. En esta última modalidad se presentaron mayor número de fracasos de VNI (AU)

The best strategy for early extubation and weaning from mechanical respiration (MV) with non-invasive ventilation (NIV) in post-surgical congenital heart defect patients has not been established yet. The aim of this study was to compare the efficacy of continuous positive airway pressure CPAP) vs bi-level positive airway pressure (BIPAP) in the elective extubation of these patients. A prospective study was conducted between June 1, 2008 and March 31, 2010. Patients that were candidates for elective extubation were randomized to CPAP or BIPAP. Data on demographics and surgical procedure, among others, were recorded. Failure of NIV was defined as the need for reintubation within 72 hours after extubation or more than one criterion for intubation. Over the study period, 1438 patients were admitted to ICU 35. Fifty-three patients were randomized to BIPAP, of whom 49 (92%) were successfully extubated; however, four were reintubated due to heart failure. Forty-six patients were randomized to CPAP. Extubation failed in 18 (39%) due to multiple episodes of desaturation and apneas. Eleven of 18 required endotracheal reintubation and mechanical ventilation. Seven patients were switched to BIPAP and remained extubated, although the switch was not part of the study design. In the weaning of post-surgical congenital heart defect patients from MV, BIPAP was more effective than CPAP. In the latter modality, the incidence of NIV failure was higher (AU)

Isolation of Salmonella spp. from liquid and solid excreta prior to and following ensilage in ten swine farms located in central Mexico.

A study was carried out to define selected bacteriological characteristics of residues from 10 swine farms, 5 with or without prior clinical enteric disease (PCED) and to determine the effect of ensilage on the bacteria present in the solid fraction. At each farm, samples were taken from the sedimentation basin (SB), the solid fraction (SF), and the liquid fraction (LF). For each sample, CFU/g for enteric bacteria were quantified; Salmonella spp. were isolated and typified. Solid phase samples from each farm were used to prepare the ensilage, with a mixture of solids (80%), sorghum (12%) and molasses (8%). The quantity of enteric bacteria was significantly greater in farms without PCED (P < 0.05). Salmonella enterica were isolated from 8/10 of the farms with and without PCED; in 8 from SB; in 6 from LF; and in 5 from SF. Enteric bacteria were not isolated from silage, therefore, ensilage may be an alternative treatment for excreta that allows the elimination of pathogens such as Salmonella spp.

Persistence of Escherichia coli, Salmonella choleraesuis, Aujeszky's Disease virus and Blue Eye Disease virus in ensilages based on the solid fraction of pig faeces.

AIMS: This study was carried out to determine the survival time of Escherichia coli, Salmonella choleraesuis, Aujeszky's Disease virus and Blue Eye Disease virus in ensilages based on the solid fraction of pig faeces. METHODS AND RESULTS: The four micro-organisms were inoculated into microsilos based on the solid fraction of pig faeces, sorghum and molasses. They were left for 0, 7, 14, 28 and 56 days, after which the state of each microsilo was evaluated, and isolation of the inoculated agents was attempted. The four inoculated agents were isolated only on day 0 of ensilage. The viral agents were identified through the cytopathic effect and fluorescence. CONCLUSIONS, SIGNIFICANCE AND IMPACT OF THE STUDY: It is concluded that ensilages based on the solid fraction of pig faeces appear to reduce the risk of the transmission of the agents inoculated in this study and help to reduce the environmental impact by using the solid in animal feed.

Exocrine pancreatic insufficiency in tropical sprue.

BACKGROUND: Pancreatic insufficiency may appear secondary to several intestinal disorders. It may contribute to malabsorption in tropical sprue (TS). METHODS: The exocrine pancreatic function was evaluated with the indirect pancreolauryl test (PT) in 56 patients with TS. The PT results were analyzed and correlated with serum albumin levels, degree of intestinal atrophy, and steatorrhea. RESULTS: Abnormally low values were found in 36 (64.2%) cases. A significant relationship was not observed between PT and hypoalbuminemia. Patients with more severe damage by intestinal biopsy tended to have lower PT values. No relationship was found between pancreatic insufficiency and steatorrhea (expressed as g/24 h), but patients with pancreatic insufficiency had increased stool fat concentrations (expressed as percentage of wet stool weight). All patients responded favorably to treatment with folic acid and tetracycline. Fifteen patients with abnormal initial PT values underwent a repeat PT after a 6-week therapy; all of them showed normalization of PT values. CONCLUSIONS: The abnormal exocrine pancreatic function found with an indirect test in patients with TS is probably secondary to a low pancreatic hormonal stimulation due to intestinal damage, as occurs in celiac sprue. These abnormalities are reversible after specific treatment for TS.

Participation of ABH glycoconjugates in the secretory response to Escherichia coli heat-labile toxin in rabbit intestine.

The ability of membrane ABH blood group-active glycoconjugates to act as receptors of the heat-labile enterotoxin of Escherichia coli (LTh) was studied in vitro and in vivo when GM1 was blocked by the cholera toxin B subunit. Rabbits were classified as AB or H based on intestinal ABH-antigenic activities. Brush border membranes from AB rabbits contained 4 times more LTh binding sites than the H ones. LTh interaction could be inhibited by lectins that recognize ABH determinants. LTh induced a similar dose-dependent secretory response in ligated ileal loops of both types of animals. Anti-AB antibodies and Ulex europaeus I lectin could significantly reduce the fluid accumulation in AB and H rabbits, respectively. LTh caused adenylate cyclase activation even when GM1 was blocked, and this effect was abolished by the addition of specific ABH ligands. These results suggest that ABH glycoconjugates are involved in the host secretory response to LTh in rabbit intestine.

Interaction of cholera toxin and Escherichia coli heat-labile enterotoxin with glycoconjugates from rabbit intestinal brush border membranes: relationship with ABH blood group determinants.

The capacity of cholera toxin (CT) and type I heat-labile enterotoxin produced by Escherichia coli isolated from human intestine (LTh) to interact with glycoconjugates bearing ABH blood group determinants from rabbit intestinal brush border membranes (BBM) was studied. On the basis of the type of intestinal compounds related to the human ABH blood group antigens, rabbits were classified as AB or H. Toxin binding to the intestinal glycolipids and glycoproteins depends on the blood group determinant borne by the glycoconjugate and on the analyzed toxin. LTh was capable of interacting preferentially with several blood group A- and B-active BBM glycolipids compared to those isolated from animals lacking these antigens (H rabbits). Also, LTh preferably bound to several BBM glycoproteins from AB rabbit intestines compared to those from H ones. One of these glycoproteins, the sucrase-isomaltase complex (EC 3.2.1.48-10) isolated from AB and H rabbits showed the same differential LTh binding. Conversely, CT practically did not recognize either blood group A-, B-, or H-active glycolipids and glycoproteins. These results may be relevant for carrying out in vivo experiments in rabbits in order to disclose the role of ABH active-glycoconjugates in the secretory response induced by LTh in rabbit intestine.

[Detection of immunoglobulin A in serum and saliva of patients with hepatitis A]. / Detección de inmunoglobulina A en suero y saliva de pacientes con hepatitis A.

Specific secretory serum IgA antibodies to the hepatitis A virus from samples from patients with clinical symptoms compatible to hepatitis A, their contacts, and healthy subjects were analyzed using an ELISA technique; results were compared with those of specific serum IgM antibodies to the hepatitis A virus. The following results were attained in 175 blood samples: coincidence by 98.8%; sensitivity by 96.8%; and specificity by 100%. Two cases were negative to IGA and positive to IGM. On comparing the presence of IGA in saliva with the presence of IGM in blood, coincidence was of 88.1%; sensitivity, of 40.9% and specificity, of 100%. Of the 22 cases with positive IGM in blood, only 9 showed specific IGA antibodies in the saliva. The 111 cases who had negative IGM in blood were also negative to IGA. The obtained data suggest that specific serum IGA antibodies to the hepatitis A virus are an indicator of a recent or occurrent infection due to this virus and thus it may be considered and alternative for the diagnosis of this disease.

[The laboratory diagnosis of the intestinal malabsorption syndrome of intestinal origin]. / Diagnóstico por laboratorio del síndrome de absorción intestinal deficiente de origen intestinal.

Normal absorption and digestion occurs in sequential stages. In the lumen of the proximal intestine pancreatic enzymes and bile salts transform complex substances in simple products which can be absorbed by the enterocyte and transported by lymphatics or portal veins. Malabsorption syndromes can be secondary to alterations in both digestion and/or absorption process. We herein review the tests used to establish the diagnosis of intestinal malabsorption syndromes with special reference to those available in our country. Finally we propose an algorithm taking into account the frequency of diseases causing malabsorption in Mexico.

[The in-vitro digestive availability of lipase and trypsin in pancreatic supplements under different degrees of acidity]. / Disponibilidad digestiva in vitro de lipasa y tripsina en suplementos pancreáticos bajo diferentes grados de acidez.

We evaluated the in vitro disintegration time and the remanent digestive activity of eight pancreatic supplements under pH conditions similar to the gastrointestinal tract. They were incubated for 45 min at various pH levels (1, 3 or 6) and continued thereafter at pH 6, for another 135 min. The activities of lipase and trypsin were evaluated titrimetrically every 15 min. At pH 6, the products without an enteric coat and Creon, showed the shortest disintegration times; under acidic conditions, those times were longer in all the enteric coated products. At constant pH 6, lipase activity was greater in Creon, Pankreon and Cotazym-B; trypsin activity was greater in Nutrizym-C, Onoton and Cotazym-B. After acidic pH exposure enzyme bioavailability was decreased in all the products. Disintegration times and acid inactivation of enzymes, should be considered when prescribing PS.

Serum testosterone:dihydrotestosterone ratio and CA 19-9 in the diagnosis of pancreatic cancer.

The testosterone:dihydrotestosterone ratio (T:DHT) and the antigenic marker CA 19-9 were studied in the serum of 21 male patients with pancreatic cancer and 62 controls with other gastrointestinal malignancies or benign pancreatobiliary disease. Specificity of the T:DHT ratio was 98%, significantly better than the specificity of CA 19-9 at both a 37 U/ml cutoff level (61%) and at 100 U/ml (79%). Sensitivity of the T:DHT ratio was 67%, and that of CA 19-9, 71% and 90% at the upper and lower cutoff levels, respectively. False-negative results of the T:DHT ratio were found predominantly in cases of advanced pancreatic cancer, whereas all four stage I patients had an abnormal (less than 5) T:DHT ratio. These results suggest that the T:DHT ratio is a useful marker for pancreatic cancer in males. It can be used alone or in combination with CA 19-9, and should be further evaluated in the differential diagnosis of patients with the early stages of this disease.

[Serum macroamylase in a subject with non-Hodgkin's lymphoma]. / Macroamilasemia en un sujeto con linfoma no-Hodgkin.

Macroamylasemia (MA) is a rare condition characterized by an active macromolecular complex formed by normal amylase with abnormal proteins; to our knowledge, it has not been previously described in Mexico. The size of the macromolecular complex precludes its renal excretion; thus MA is characterized by high levels of amylase in serum with normal amylasuria. We report a 53-year-old male with abdominal pain and hyperamylasemia who was erroneously diagnosed as pancreatitis. Amylase in urine was normal and a protein electrophoresis demonstrated hyperglobulinemia. Several months after the initial work-up, the diagnosis of non-Hodgkin's lymphoma was established. Serum pancreatic amylase was again found elevated with normal urinary amylase. Precipitation of amylase with polyethylene-glycol was of 81% (normal: less than 70%). This established the diagnosis of MA associated to non-Hodgkin's lymphoma. After chemotherapy, the abnormal macroamylasemia and hyperglobulinemia disappeared.

[Diagnostic usefulness of Ca 19-9 antigen in cancer of the pancreas and neoplasms of the pancreato-biliary intersection]. / Utilidad diagnóstica del antígeno CA 19-9 en cáncer de páncreas y neoplasias de la encrucijada pancreatobiliar.

Antigen CA 19-9 was measured in the serum of a group of 16 patients with pancreatic cancer, in 19 patients with non-pancreatic gastrointestinal malignancies, and in 19 others with benign pancreatobiliary disease. The test showed a high sensitivity with a low specificity and a positive predictive value for diagnosis of pancreatic cancer when confronted with a group of controls that included both benign and malignant gastrointestinal disease. The low specificity was due to high CA 19-9 values in other gastrointestinal cancers, especially in carcinoma of the ampulla and the biliary tract. When the latter were added to the group of patients with pancreatic cancer, and the diagnostic accuracy of the test was re-evaluated, sensitivity, specificity and both positive and negative predictive values increased. Values of CA 19-9 over 100 U/ml are highly predictive of malignancy in patients with pancreato-biliary disease.

[Vegetable protein diets with or without non-absorbable antibiotics for the treatment of chronic portal systemic encephalopathy]. / Son necesarios los antibioticos inabsorbibles en pacientes con encefalopatía hepática manejados con dieta de proteínas vegetales?

Five patients with mild chronic portal systemic encephalopathy (PSE) were studied. The study was designed in a double cross over fashion in which each patient received during period I a 40 g vegetable protein diet as single treatment. During period II three g/day of oral kanamycin were added and then new periods of single vegetable protein diet (period III) and vegetable protein diet plus kanamycin (period IV) were introduced (identical to periods I and II respectively). Each period lasted two weeks. Several biweekly assessements-tests were determined including: mental state, asterixis grade, electroencephalograms, number connection tests, figure connection tests, blood ammonia levels and stool counts of total aerobes/anaerobes per g/feces were done. During the study none of the patients developed acute encephalopathy. In any case it was detected a significant improvement of the PSE parameters assessed with the addition of oral kanamycin. Fecal counts were very similar during the various periods of the study. We conclude that in mild portal systemic encephalopathy controlled with vegetable protein diet, the addition of non absorbable antibiotics is not mandatory for the management of these patients and may represent a potential risk of serious side effects. At the beginning of treatment vegetable protein diet should be administered and only in case of failure, antibiotics are to be indicated.

Effects of synthetic steroid contraceptives on biliary lipid composition of normal Mexican women.

The effects of two hormonal contraceptives upon the biliary lipid composition of Mexican women were evaluated in a prospective study. Twenty-one healthy volunteers of reproductive age were allocated into three groups (7 subjects each). Group I served as the experimental control (all subjects were bearing a non-medicated IUD), group II received i.m. norethisterone enanthate (NET-e) 200 mg every two months, and group III received an oral combination of 1-norgestrel 150 micrograms and ethinyl estradiol 30 micrograms. The bile lithogenic index as assessed by the relative proportion of cholesterol to bile acids and lecithin was determined in duodenal bile samples obtained before (baseline), during (4 months), and after (12 months) contraceptive administration. The results indicated that NET-e administration resulted in a slight although significant increase of the lithogenic index while the oral formulation did not. The overall data were interpreted as demonstrating that administration of these steroid contraceptives does not constitute a risk factor in terms of gallstone formation in the population studied. The estrogen-like behavior exhibited by NET-e is discussed.

PIP: The effects of 2 hormonal contraceptives upon the biliary lipid composition of Mexican women were evaluated in a prospective study. 21 healthy volunteers of reproductive age were assigned to 3 groups (7 subjects each). Group 1 served as the experimental control (all subjects wore a nonmedicated IUD), group 2 received 200 mg norethisterone enanthate (NET-e) intramuscularly every 2 months, and group 3 received an oral combination of 150 mcg l-norgestrel and 30 mcg ethinyl estradiol. The bile lithogenic index as assessed by the relative proportion of cholesterol to bile acids and lecithin was determined in duodenal bile samples obtained before (baseline), during (4 months), and after (12 months) contraceptive administration. Results indicated that NET-e administration resulted in a slight although significant increase of the lithogenic index while the oral formulation did not. The overall data were interpreted as demonstrating that administration of these steroid contraceptives does not constitute a risk factor in terms of gallstone formation in the population studied. The estrogen-like behavior exhibited by NET-e is discussed.