Efficacy of an information system addressed to nursing staff for diminishing contaminated blood cultures: a blind clinical trial.

OBJECTIVE: Evaluate the efficacy of an information system addressed to nursing staff to lower the blood culture contamination rate. METHODS: A blind clinical trial was conducted at Internal Medicine and Emergency Departments during 2011. After following a reeducation program in BC extraction, participants were randomly selected in a 1:1 ratio. Every participant of the experimental group was informed of each worker's individual performance; whereas the control group was only informed of the global results. RESULTS: A total of 977 blood extractions were performed in 12 months. Blood culture contamination rate was 7.5%. This rate was higher in the Emergency Department than in Internal Medicine (10% vs. 3.8%; p=0.001). Factors associated with the higher risk of contamination were, in the univariate analysis, the extraction through a recently implanted blood route and the time of professional experience, while those associated with a lower risk were the extraction in Internal Medicine and through a butterfly needle. On multivariate analysis, extraction through a recently placed access was an independent risk factor for an increased contamination rate (OR 2.29; 95%CI 1.18-4.44, p=0.014), while individual information about the blood culture results (OR 0.11; 95%CI 0.023-0.57; p=0.008), and more than 9 years of professional experience were asso-ciated with fewer contaminations (OR 0.30; 95%CI 0.12-0.77; p=0.012). In the intervention group the contamination rate diminished by a 26 %. CONCLUSIONS: Drawing blood cultures through a recently taken peripheral venous access increased their risk of contamination. The intervention informing the nurse staff of the contamination rate is effective to decrease it.

[Risk factors and clinical evolution of carbapenemase-producing Klebsiella pneumoniae infections in a university hospital in Spain. Case-control study]. / Factores de riesgo y evolución clínica de las infecciones causadas por Klebsiella pneumoniae productora de carbapenemasas en un hospital universitario de España. Estudio de casos y controles.

OBJECTIVE: Carbapenemase-producing Enterobacterias is a global health hazard due to their ease of transmission, difficulty of treatment, and their personal and economic impact. We analyze the factors associated with an increased risk of infection by Klebsiella pneumoniae carbapenemase-producing bacteria (KPC) and factors related to poor prognosis. METHODS: We designed a case-control study. KPC isolates were taken during an outbreak in a hospital in Madrid. A logistic regression was performed with the main variables. RESULTS: Sixteen cases of clinically documented infections were isolated. Overall mortality rates in the cases group was 25%. The most frequent location was blood (37.5%) followed by urine (25%). All but one were OXA-48. Regarding factors related to an increased risk of developing infection, only previous exposure to antibiotics presented statistical significance difference OR 13 (2.40-70.46). With respect to the overall mortality, the presence of pneumonia OR 25 (1.93-323.55) or the use of invasive mechanical ventilation was associated with greater risk 15 OR 33 (1.92-122.8) For attributable mortality only invasive ventilation had a significant association OR 18 (1.48-218.95). CONCLUSIONS: Exposure to previous antibiotics is an independent risk factor for developing KPC infection, adjusted for all other clinical and demographic variables. Risk factors such as the presence of pneumonia or the use of invasive mechanical ventilation were associated with a worse prognosis in terms of overall and attributable mortality.

Inyectables de larga duración, de la farmacología a la clínica / No disponible

Los antipsicóticos inyectables de larga duración (AILD) y en particular los de segunda generación constituyen un elemento clave en el abordaje de los pacientes con esquizofrenia u otros trastornos psicóticos debido a su capacidad de asegurar la libe-ración de niveles plasmáticos estables del principio activo y asegurando así una mayor adherencia al tratamiento. A pesar de la probada eficacia y el mejor perfil de tolerabilidad de los AILD de segunda generación, estos fármacos son ampliamente infrau-tilizados y con frecuencia son relegados a etapas más avanzadas de la enfermedad a pesar de lo recomendado por la mayoría de guías clínicas internacionales. Aunque hay importantes diferencias entre los diversos AILD, este grupo de fármacos muestran importantes ventajas clínicas frente a los tratamientos orales

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Valores de presión arterial obtenidos en población adolescente de la Comunidad de Madrid: Tablas basadas en el estudio MEPAFAC / Blood pressure values in adolescents in the Community of Madrid: Tables based on the MEPAFAC Study

Introducción: La hipertensión arterial (HTA) es un factor de riesgo cardiovascular modificable y su detección en edades tempranas podrá permitir el diseño de estrategias para reducir el riesgo vascular en edades adultas. Objetivos: Aportar valores de medida de presión arterial (PA) obtenidos con aparatos oscilométricos y fuera de la consulta médica. Material y métodos: La PA fue medida con aparato oscilométrico validado, siguiendo el documento de consenso de la Sociedad Europea de Hipertensión. También se midieron la talla y el peso. Para relacionar los valores percentilados (90-95-99) de PA sistólica (PAS) y la PA diastólica PAD) con edad, sexo y talla se optó por utilizar la talla agrupada: T150 (≤150 cm), T160 (151-160 cm), T170 (161-170 cm) y T180 (≥171 cm). Resultados: Se incluyeron 2.758 adolescentes de entre 12 y 17 años. La PA aumenta con la edad, con diferencias de hasta 11 mmHg en chicos vs. 3 mmHg en chicas para PAS y de 3vs. 1 mmHg para PAD. En PAS elevada, para los más jóvenes, la diferencia en función de la altura es de 15mmHg en chicos vs. 8 mmHg en chicas, sin existir aumento significativo en los más mayores en ningún género. La PAD elevada varía en función de la talla: 10 mmHg en los chicos pequeños y 3 mmHg en los mayores, mientras que en las chicas la variación es de 3mmHg para todas las edades. Conclusiones: Los valores de PAS/PAD en los adolescentes aumentan con la edad y, sobre todo, con la altura: las cifras llegan a ser muy similares en los más altos, independientemente de la edad

Introduction: High blood pressure (HBP) is a modifiable cardiovascular risk factor and its detection at early ages may allow strategies to be designed to reduce cardiovascular risk in adulthood. Objectives: To provide blood pressure (BP) values in a sample of adolescents using an electronic oscillometric device. Material and methods: BP was measured according the European Society of Hypertension guidelines using an oscillometric device. Height and weight were also measured. Four height groups were used in order to associate the 90, 95, and 99 percentiles with systolic BP (pSBP) and diastolic BP percentiles (pDBP) for sex and age: H150 (≤ 150cm), H160 (151-160 cm), H170 (161-170 cm), and H180 (≥171 cm). Results: Data from 2,758 students aged 12-17 years were included in the analysis. BP increases with age, with differences of up to 11 mmHg in boys vs. 3 mmHg in girls for SBP and 3 mmHg vs. 1mmHg for DBP. In high SBP, for the younger adolescents, the difference related to height was 15 mmHg in boys vs. 8 mmHg in girls, with no significant increase in the older ones in either gender. The high BDP varied depending on the height, 10 mmHg in younger boys and 3 mmHg in older ones, while in girls the variation was 3mmHg for all ages. Conclusions: SBP/DBP in adolescents increases with age and also with height, giving similar figures in the taller ones, regardless of age

[Blood pressure values in adolescents in the Community of Madrid: Tables based on the MEPAFAC Study]. / Valores de presión arterial obtenidos en población adolescente de la Comunidad de Madrid: Tablas basadas en el estudio MEPAFAC.

INTRODUCTION: High blood pressure (HBP) is a modifiable cardiovascular risk factor and its detection at early ages may allow strategies to be designed to reduce cardiovascular risk in adulthood. OBJECTIVES: To provide blood pressure (BP) values in a sample of adolescents using an electronic oscillometric device. MATERIAL AND METHODS: BP was measured according the European Society of Hypertension guidelines using an oscillometric device. Height and weight were also measured. Four height groups were used in order to associate the 90, 95, and 99 percentiles with systolic BP (pSBP) and diastolic BP percentiles (pDBP) for sex and age: H150 (≤ 150cm), H160(151-160cm), H170(161-170cm), and H180(≥171cm). RESULTS: Data from 2,758 students aged 12-17 years were included in the analysis. BP increases with age, with differences of up to 11mmHg in boys vs. 3mmHg in girls for SBP and 3mmHg vs. 1mmHg for DBP. In high SBP, for the younger adolescents, the difference related to height was 15mmHg in boys vs. 8mmHg in girls, with no significant increase in the older ones in either gender. The high BDP varied depending on the height, 10mmHg in younger boys and 3mmHg in older ones, while in girls the variation was 3mmHg for all ages. CONCLUSIONS: SBP/DBP in adolescents increases with age and also with height, giving similar figures in the taller ones, regardless of age.

Effect of co-management with Internal Medicine on hospital stay in Ophthalmology.

OBJECTIVE: Patients admitted to the Department of Ophthalmology (OPH) are of increasing age, comorbidity and complexity, leading to increased consultations/referrals to Internal Medicine (IM). An alternative to consultations/referrals is co-management. The effect of co-management on length of hospital stay was studied in patients admitted to OPH. METHODS: Retrospective observational study was performed that included patients ≥14 years old discharged from OPH between 1 January 2009 and 30 June 2013, who were co-managed from May 2011. An analysis was made including age, sex, type of admission, whether it was operated on, administrative weight associated with GRD, total number of discharge diagnoses, Charlson comorbidity index (CCI), mortality, readmissions, and LoS. RESULTS: There were statistically significant differences between the groups in operated patients (odds ratio [OR] 2.3, 95% confidence interval [95% CI] 1.5 to 3.6), administrative weight (0.1160; 95% CI 0.0738 to 0.1583), and number of diagnoses (0.9, 95% CI 0.5 to 1.3). On adjustment, co-management reduced LoS in OPH by 27.8%, 0.5 days (95% CI 0.1 to 1). CONCLUSIONS: Patients admitted to OPH have increasing comorbidity and complexity. Co-management is associated with a reduced LoS and costs in OPH, similar to that observed in other surgical services.

Documento de consenso sobre el manejo de la patología renal en pacientes con infección por VIH / Consensus document on the management of renal disease in HIV-infected patients

OBJETIVO: Actualizar las recomendaciones sobre la evaluación y el manejo de la afectación renal en pacientes con infección por el virus de la inmunodeficiencia humana (VIH). MÉTODOS: Este documento ha sido consensuado por un panel de expertos del Grupo de Estudio de Sida (GESIDA) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), de la Sociedad Española de Nefrología (S.E.N.) y de la Sociedad Española de Química Clínica y Patología Molecular (SEQC). Para la valoración de la calidad de la evidencia y la graduación de las recomendaciones se ha utilizado el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTADOS: La evaluación renal debe incluir la medida de la concentración sérica de creatinina, la estimación del filtrado glomerular (ecuación chronic kidney disease epidemiological collaboration [CKD-EPI]), la medida del cociente proteína/creatinina en orina y un sedimento urinario. El estudio básico de la función tubular ha de incluir la concentración sérica de fosfato y la tira reactiva de orina (glucosuria). En ausencia de alteraciones, el cribado será anual. En pacientes tratados con tenofovir o con factores de riesgo para el desarrollo de enfermedad renal crónica (ERC), se recomienda una evaluación más frecuente. Se debe evitar el uso de antirretrovirales potencialmente nefrotóxicos en pacientes con ERC o factores de riesgo para evitar su progresión. En este documento se revisan las indicaciones de derivación del paciente a Nefrología y las de la biopsia renal, así como las indicaciones y la evaluación y el manejo del paciente en diálisis o del trasplante renal. CONCLUSIONES: La función renal debe monitorizarse en todos los pacientes con infección por el VIH y este documento pretende optimizar la evaluación y el manejo de la afectación renal.(AU)

OBJECTIVE: To update the 2010 recommendations on the evaluation and management of renal disease in HIV-infected patients. METHODS: This document was approved by a panel of experts from the AIDS Working Group (GESIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Nephrology (S.E.N.), and the Spanish Society of Clinical Chemistry and Molecular Pathology (SEQC). The quality of evidence and the level of recommendation were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: The basic renal work-up should include measurements of serum creatinine, estimated glomerular filtration rate by CKD-EPI, Urine protein-to-creatinine ratio, and urinary sediment. Tubular function tests should include determination of serum phosphate levels and urine dipstick for glucosuria. In the absence of abnormal values, renal screening should be performed annually. In patients treated with tenofovir or with risk factors for chronic kidney disease (CKD), more frequent renal screening is recommended. In order to prevent disease progression, potentially nephrotoxic antiretroviral drugs are not recommended in patients with CKD or risk factors for CKD. The document advises on the optimal time for referral of a patient to the nephrologist and provides indications for renal biopsy. The indications for and evaluation and management of dialysis and renal transplantation are also addressed. CONCLUSIONS: Renal function should be monitored in all HIV-infected patients. The information provided in this document should enable clinicians to optimize the evaluation and management of HIV-infected patients with renal disease.(AU)

Higher vitamin D levels in HIV-infected out-patients on treatment with boosted protease inhibitor monotherapy.

OBJECTIVES: We investigated the vitamin D status of patients receiving frequently used types of combination antiretroviral therapy (cART), including boosted protease inhibitor (PI) monotherapy. METHODS: For this cross-sectional study, out of 450 HIV-infected patients followed in the Hospital Severo Ochoa (Madrid, Spain), we selected 352 patients for whom vitamin D levels had been measured (January 2009 to December 2010). We collected the following data: demographics, cART duration, main cART regimen, viral load (VL), CD4 cell count, and concentrations of 25(OH)-vitamin D [25(OH)-D], parathyroid hormone (PTH), albumin and calcium. Vitamin D status cut-off points were: (1) deficiency (vitDd): 25(OH)-D < 20 ng/mL; (2) insufficiency (vitDi): 25(OH)-D from 20 to 29.99 ng/mL; and (3) optimal (vitDo): 25(OH)-D ≥ 30 ng/mL. RESULTS: The percentages of patients with vitDd, vitDi and vitDo were 44, 27.6 and 28.5%, respectively. Twenty-nine out of 30 (96.7%) Black patients had vitDd or vitDi, vs. 71.6% in the global sample (P < 0.001). Former injecting drug users (IDUs) had a higher prevalence of vitDo (P < 0.001) than patients in other transmission categories. Among patients with vitDd, vitDi and vitDo, the proportions of patients with a VL ≤ 50 HIV-1 RNA copies/mL were 77.4, 68 and 91%, respectively (P < 0.0001). Of the cART regimens, only boosted PI monotherapy was associated with significant differences in vitamin D levels (P = 0.039). Multivariate logistic regression analysis showed an increased risk of vitDi or vitDd associated with the following variables: Black vs. Caucasian ethnicity [odds ratio (OR) 10.6; 95% confidence interval (CI) 1.2-94; P = 0.033]; heterosexual (OR 2.37; 95% CI 1.13-4.93; P = 0.022) or men who have sex with men (MSM) (OR 3.25; 95% CI 1.25-8.50; P = 0.016) transmission category vs. former IDU; and VL > 50 copies/mL (OR 2.56; 95% CI 1.10-7.25; P = 0.040). A lower risk of vitamin D insufficiency or deficiency was found in patients on boosted PI monotherapy vs. no treatment (OR 0.08; 95% CI 0.01-0.6; P = 0.018). CONCLUSIONS: Our data show an increased risk of vitamin D deficiency or insufficiency in patients with detectable VL and a Black ethnic background. Among cART regimens, boosted PI monotherapy was associated with a lower risk of vitamin D deficiency or insufficiency. The more favourable vitamin D status in former IDUs was probably attributable to a higher frequency of outdoor jobs in this group of patients.

The changing pattern of tuberculosis and HIV co-infection in immigrants and Spaniards in the last 20 years.

OBJECTIVES: To evaluate the impact of immigration on tuberculosis (TB)-HIV co-infection in Spain in a prospective cohort of HIV patients. METHODS: Among 7761 HIV patients, we evaluated 1284 with at least one episode of TB between 1987 and 2006. Variables were compared between immigrants and Spaniards. RESULTS: Incidence of TB decreased from 20 to five cases per 100 patient-years in 2006 (P<0.01) and was always higher in immigrants than in Spaniards. The proportion of immigrants increased, reaching almost 50% of both new cases of HIV and TB-HIV co-infection in 2006. In 34.4% of patients, TB and HIV infection were diagnosed within the same year; simultaneous diagnosis was more frequent in immigrants (83.3%vs. 16.7%, P<0.001). Mortality was associated independently with age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01-1.05], TB diagnosis before 1996 (HR 2.6, 95% CI 1.8-3.6), use of highly active antiretroviral treatment (HR 0.494, 95% CI 0.37-0.66) and CD4 cell count at TB diagnosis (HR 0.996, 95% CI 0.995-0.997). CONCLUSIONS: Immigrants have a major impact on the incidence of TB in HIV patients, slowing down the decreasing trend in Spain. Simultaneous diagnosis of the co-infection in immigrants reveals a need to intensify HIV case finding in immigrants in Spain.

Economic evaluation of assistance to HIV patients in a Spanish hospital.

BACKGROUND: Little is known about the global effects of HAART on the use of medical resources after the complete implementation of this therapy in Spain. This study was designed to determine the use of medical resources and the costs of health care for HIV-infected patients. METHODS: All patients with HIV infection who came to our institution during the year 2002 were included in the study. We analyzed the global assistance data and pharmaceutical costs during the year. Costs were calculated based on a unitary cost for DRG and an officially assigned standard cost for outpatient clinic, visits to the day care unit and to the emergency room (ER), outpatient surgery, and total costs of pharmacy. RESULTS: The total cost for HIV-related health care assistance was euro739,048. The cost related to admissions was euro150,766.60; euro8631 per first visit and euro49,199.40 per successive visit; euro5085.10 per day care unit; euro14,920 per outpatient surgery; euro7655.70 per ER visit; and euro491,342.40 per antiretroviral treatment. A significant proportion of the total outpatient assistance was given by physicians other than HIV specialists, namely, 63% of the costs attributed to the first visit and 41% per successive visit. CONCLUSION: More than 50% of the costs of caring for HIV-infected patients are still attributed to antiretroviral therapy. Specialists other than infectious disease specialists provide a significant proportion of outpatient assistance. A method to control HIV costs is greatly needed.

Isquemia intestinal intermitente en relación con tumor / Intermittentintestinal ischemia caused by ileal carcinoid tumor

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[Chylothorax as presenting form of a gastric adenocarcinoma]. / Quilotórax como forma de presentación de un adenocarcinoma gástrico.

Malignancies other than lymphoma can in rare instances induce the development of chylothorax. A patient with this unusual type of pleural effusion is described herein. The need to rule out a gastric neoplasm when confronted with a case of chylothorax with no obvious cause is stressed.

[Primary leiomyosarcoma of the liver]. / Leiomiosarcoma primario de hígado.

We report a case of primary hepatic leiomyosarcoma in a 70 years old woman presenting with hepatomegaly, right upper quadrant pain and impairement of general status. A left hemihepatectomy was undertaken revealing a single tumor of 7 cm in diameter in the left hepatic lobe. An immunohistochemycal study was performed indicating the smooth muscle nature of the tumor. The patient died 6 months later without evidence of active tumoral disease. This is the 28th report on primary leiomyosarcoma of the liver in the world literature.

[Effect of overexpression of P53 protein in colorectal carcinoma on short-term prognosis]. / Influencia en el pronóstico a corto plazo de la sobreexpresión de la proteína P53 en carcinomas colorrectales.

BACKGROUND AND METHODS: p53 protein expression was studied immunohistochemically in 73 colorectal adenocarcinomas, using monoclonal antibody D07 in alcohol fixed, paraffin embedded tissue. RESULTS: Immunoreactivity was found in 49% of specimens, detected in the nuclei of the cancer cells. There was no significant correlation between the expression of p53 and the clinicopathological parameters age, sex, tumor size and site, lymphatic invasion, and lymph node metastasis. However, the p53 overexpression correlated with stage of disease, histologic grade, vascular invasion and with the presence of villous or tubular adenomas in the resected specimens. The p53 positive tumors showed a higher rate of recurrence than the p53 negative tumors; however, the difference was not statistically significant. The short-term survival rate (follow-up 7-48 months, median 30 months) was 90% for 20 patients with p53 negative tumors, and 65% for the patients with p53 positive tumors; a significant difference in the survival between the two groups of patients was found. CONCLUSIONS: These results suggest that in colorectal carcinoma, immunohistochemical detection of p53 protein can be used along with other established indicators to asses prognostic outcome, specially to identify patients with a poor short-term prognosis.