Implantación de receta XXI en el Centro de Salud de Benahadux (Almería) / Introduction of XXI rrescription in the Benahadux Health Centre (Almería, Spain)

No disponible

Alteraciones del desarrollo mamario / Aberrations of normal breast development

La glándula mamaria es, en nuestra especie, algo más que un simple órgano productor de leche. Desempeña un papel importante como órgano sexual y está sometido a la variabilidad de los cánones de belleza impuestos por las distintas modas. Las alteraciones mamarias se dividen en aquellas que aparecen desde el nacimiento (congénitas) y las provocadas por un mal desarrollo (adquiridas). Ambas pueden resultar bien por un exceso o por un defecto tanto en su número como en su crecimiento o tamaño y afectar a toda la mama o limitarse al complejo areola pezón (AU)

Procesos inflamatorios de la mama / Inflammatory diseases of the breast

Las enfermedades inflamatorias de la mama o mastitis suponen la respuesta clínica a la agresión infecciosa, tumoral, traumática o de otro tipo sobre la mama. La mastitis puerperal es el proceso más frecuente. Se clasifican en agudas y crónicas y estas últimas abarcan una serie de procesos específicos e inespecíficos. En la mastitis aguda el diagnóstico es clínico y el tratamiento médico salvo cuando existe un absceso cuyo tratamiento es el drenaje quirúrgico. El germen más frecuentemente aislado es el Stafilococo aureus. En las mastitis crónicas es necesaria, en muchos casos, una biopsia para establecer un diagnóstico diferencial con el cáncer de mama. El tratamiento es frecuentemente médico pero en muchos casos es preciso realizar una tumorectomía llegando en casos extremos a precisar de mastectomía simple. Algunos procesos inflamatorios están limitados al complejo areola-pezón (AU)

Alcohol consumption and the risk of nosocomial infection in general surgery.

BACKGROUND: Alcohol consumption increases community-acquired infections and affects the immune system. The aim of this report was to analyse whether drinking increases the risk of nosocomial infection. METHODS: This was a prospective study of 1505 patients admitted consecutively to a general surgical department. Alcohol consumption was assessed by a structured questionnaire. Postoperative infection was classified using the Centers for Disease Control criteria. Confounding was controlled for by logistic regression analysis, and the results were stratified by gender and drinking pattern. RESULTS: Most women were light drinkers and no increased risk of postoperative infection was noted. In men, drinking was associated with a lower American Society of Anesthesiologists grade and fewer co-morbidities. Heavy alcohol consumption (more than 108 g/day) in men increased the rate of all-site nosocomial infection (adjusted odds ratio (OR) 2.51, 95 per cent confidence interval (c.i.) 1.06 to 5.96) and the rate of in-hospital surgical-site infection (SSI) (adjusted OR 2.16, 95 per cent c.i. 0.84 to 5.58). An intake of above 72 g/day increased the rate of lower respiratory tract infection (adjusted OR 5.22, 95 per cent c.i. 1.04 to 26.2). Alcohol consumption was not related to the rate of SSI after hospital discharge. When drinking was limited to weekends, there was no relationship with nosocomial infection. CONCLUSION: Heavy alcohol consumption increased the risk of nosocomial infection in men who underwent general surgical procedures.

Quimioprofilaxis en cirugía: problemas y soluciones en su cumplimiento / Chemoprophylaxis in surgery: problems and solutions in its performance

Desde hace 20 años los principios de la profilaxis antibiótica permanecen vigentes. No obstante, con una gran frecuencia en todos los países, desarrollados o no, se documenta que su incumplimiento es una práctica habitual en cirugía. Los estudios que han abordado el estudio de los determinantes de cumplimiento son escasos. Aunque la información es insuficiente, se ha establecido una serie de factores que pueden influir. Dentro de los factores relacionados con el paciente se encuentran el sexo, el grado de contaminación y la duración de la cirugía, si la cirugía es de urgencia o programada, el momento del día en que se realiza la cirugía, el nivel ASA y la enfermedad subyacente. Dentro de los factores dependientes del cirujano pueden influir el dogmatismo, nihilismo, arrogancia, miedo al fracaso, mercadotecnia de las casas comerciales, sensación de seguridad, falta de formación científica, no diferenciar profilaxis de tratamiento, no diferenciar inflamación de infección, trabajar o no en un hospital docente y la comprobación de que la alteración de la profilaxis recomendada no aumenta el riesgo de infección. Para conseguir que se cumplan las normas de profilaxis antibiótica se sugiere una serie de soluciones, que van desde la evaluación del grado de cumplimiento hasta el aumento de la formación científica, especialmente en la residencia donde el futuro cirujano es más moldeable y adopta las prácticas de sus tutores. (AU)

Efectividad de la prevención cardiovascular en atención primaria / Effectiveness of cardiovascular prevention in primary care

Objetivos. Evaluar la modificación de los factores de riesgo y del riesgo coronario en adultos (14-75 años) tras un período de entre 1 y 5 años de ser incluidos en el PAPPS. Diseño. Estudio multicéntrico de intervención sin asignación aleatoria antesdespués. Emplazamiento. Atención primaria. Participantes. Se evalúa a los pacientes incluidos en el PAPPS de 3 centros salud, 634 seguidos durante 5 años, 890 durante 4 años, 1.605 durante 3 años y 2.829 durante 2 años. Intervenciones. Consejo mínimo para abandonar tabaco y consumo excesivo de alcohol, medidas educacionales y farmacológicas para reducir colesterol y presión arterial. Mediciones principales. Toma de la presión arterial, colesterol, peso, consumo tabaco y alcohol. En el subgrupo 30-75 años determinación del riesgo coronario. Estas variables se determinaron al inicio y al final de los distintos períodos de seguimiento. Resultados. La reducción del riesgo coronario fue entre el 0,2 y el 0,3 por ciento, de la presión arterial sistólica entre 0,4 y 0,9 mmHg, y de la diastólica entre 0,3 y 0,7 mmHg, del colesterol entre 0,5 y 2,5 mg/dl, del porcentaje de fumadores entre el 0,3 y el 2,8 por ciento y del consumo excesivo de alcohol entre el 0,2 y el 1 por ciento. Conclusiones. Escasa repercusión de las intervenciones realizadas para reducir el riesgo coronario o los factores de riesgo en la población total. La utilidad principal de los programas de prevención cardiovascular y multifactoriales estribaría en la detección de los pacientes de alto riesgo para, posteriormente, intervenir sobre ellos (AU)

Efficacy of surveillance in nosocomial infection control in a surgical service.

OBJECTIVE: The purpose of this study was to assess the efficacy of surveillance of nosocomial infection in infection control at a service of general surgery. DESIGN: A surveillance study that included 1483 patients with a prospective identification of nosocomial infection was carried out. Its results were discussed with the staff, and a program on nosocomial infection control was implemented. One year after the pre-intervention study, a similar study that included 1506 patients was done. The main outcome measure was nosocomial infection. Incidence rates, incidence rate ratios, crude and multiple-risk factor adjusted for by Poisson regression analysis, and their 95% confidence interval rates were estimated. RESULTS: The characteristics of the patients enrolled in both studies were compared. After the intervention, the trend was to attend patients with more severe conditions: higher frequency of liver failure, chronic obstructive lung disease, higher proportion of dirty surgical wounds, and higher scores of both Study on the Efficacy of Nosocomial Infection Control (SENIC) and National Nosocomial Infections Surveillance indices. There were no significant differences in emergency surgery, duration of surgery, age, and sex. After the intervention, unnecessary chemoprophylaxis was drastically reduced, and a significant reduction in preoperative stay was observed. The nosocomial incidence rate fell from 18.4 to 14 per 1000 patient-days. This reduction yielded an incidence rate ratio of 0.56 (95% confidence interval, 0.43%-0.74%) adjusted for several variables (SENIC index, serum creatinine level, serum albumin level, antihistamine H2 level, surgical wound, body mass index, chemoprophylaxis, and community-acquired infection). Significant reductions in surgical site infection and urinary tract infection were observed, but the rate of respiratory tract infection remained unchanged. CONCLUSIONS: Surveillance was effective in reducing nosocomial infection.

Epidemiology of surgical-site infections diagnosed after hospital discharge: a prospective cohort study.

OBJECTIVE: To study postoperative infections in hospital and after discharge, and to identify the risk factors for such infections. DESIGN: Prospective cohort study, with telephone follow-up for 1 month after hospital discharge. SETTING: The general surgery service of a tertiary hospital in Spain. MAIN OUTCOME MEASURE: In-hospital and postdischarge surgical-site infection (SSI), always confirmed by a physician. RESULTS: Of the 1,506 patients initially enrolled, 29 died during hospital stay, and 33 were lost to postdischarge follow-up. An SSI was identified prior to discharge in 123 patients and after discharge in 103. For several variables (age, serum albumin, glycemia, lengths of preoperative and postoperative hospital stay, etc), there were no differences between patients with postdischarge SSI and noninfected patients; however, there were differences detected between patients with postdischarge SSI and in-hospital SSI, as well as between patients with in-hospital SSI and noninfected patients. The analysis of risk factors showed that most predictors for in-hospital SSI did not behave in the same manner for postdischarge SSI. Stepwise logistic regression only identified chemoprophylaxis, age (advanced age was a preventive factor), and body mass index as independent risk factors for postdischarge SSI. Differences in risk factors between in-hospital and post-discharge SSIs remained even after controlling for time from operation to diagnosis. CONCLUSIONS: Most predictors of in-hospital SSI were not predictors of postdischarge SSI.

[Effectiveness of cardiovascular prevention in primary care]. / Efectividad de la prevención cardiovascular en atención primaria.

OBJECTIVES: To evaluate the modification of risk factors and of coronary risk (CR) in adults (14-75 years old) after a period of 1 to 5 years in the PAPPS (special prevention programme). DESIGN: Multi-centre intervention study with no before-and-after random allocation. SETTING: Primary care. PARTICIPANTS: Patients included in the PAPPS at 3 health centres, 634 monitored for five years, 890 for four years, 1605 for 3 years and 2829 for 2 years, were evaluated.Interventions. Minimum counselling to give up tobacco and over-consumption of alcohol, and educational and pharmacological measures to reduce cholesterol and blood pressure. MAIN MEASUREMENTS: Recording of blood pressure, cholesterol, weight, and tobacco and alcohol consumption. CR was determined in the sub-group of 30-75 years old. These variables were determined at the start and end of the various monitoring periods. RESULTS: CR was reduced by between 0.2 and 0.3%; systolic blood pressure, by between 0.4 and 0.9 mmHg; diastolic pressure, by between 0.3 and 0.7 mmHg; cholesterol, by between 0.5 and 2.5 mg/dl; percentage of smokers, by between 0.3 and 2.8%; and over-consumption of alcohol, by between 0.2 and 1%. CONCLUSIONS: Scant success of the interventions to reduce CR and risk factors in the population as a whole. The main use of cardiovascular prevention programmes with many factors resides in detecting high-risk patients for subsequent intervention.

Frecuencia del cáncer de colon hereditario no asociado a poliposis. Resultados de un estudio prospectivo / Frequency of hereditary non-polyposis colon cancer. Results of a prospective study

Introducción. Presentamos un estudio prospectivo cuyo objetivo es determinar la frecuencia de cáncer de colon hereditario no asociado a poliposis (CCHNP), en los casos incidentes de cáncer colorrectal, en dos áreas hospitalarias de la provincia de Jaén. Pacientes y métodos. El objetivo del trabajo fue determinar la frecuencia de CCHNP. El estudio se llevó a cabo en la población de referencia de dos áreas hospitalarias de la provincia de Jaén (234.500 habitantes), y tuvo una duración de 2 años. Para identificar las familias con CCHNP nos hemos basado en la historia familiar de los pacientes diagnosticados de cáncer colorrectal. Para establecer el diagnóstico de CCHNP se han aplicado los criterios definidos por el International Collaborative Group on Hereditary Non- Polyposis Colorectal Cancer (criterios de Amsterdam). Resultados. Hemos estudiado la historia familiar de 173 pacientes con cáncer colorrectal. Tres familias cumplían todos los criterios diagnósticos de CCHNP. Otras dos familias presentaban una clara asociación familiar de cáncer colorrectal, aunque no cumplían de forma rigurosa los criterios de Amsterdam (probable CCHNP). Conclusiones. En la población estudiada, la frecuencia de CCHNP se sitúa entre el 1,7 por ciento (CCHNP confirmado) y el 3 por ciento (incluyendo los casos probables) de los cánceres colorrectales (AU)

Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery.

The objectives of this paper are to assess whether two indices of intrinsic infection risk (the SENIC and the NNIS index) predict in-hospital mortality and the attributable in-hospital mortality due to nosocomial infection in surgical patients. A prospective study on 4714 patients admitted to three hospitals has been carried out. The relative risk and its 95% confidence interval (CI) were estimated. Multiple-risk factors adjusted for odds ratios (OR) were yielded by logistic regression analysis. Overall, 119 patients (2.5%) died before hospital discharge. Both the SENIC and the NNIS indices were related to in-hospital mortality in crude data. After controlling for several variables (age, sex, ASA score, cancer, renal failure, diabetes mellitus, stay at the ICU), the SENIC index did not show any significant trend with mortality (P = 0.252), whereas the trend was significant for the NNIS index (P < 0.001). Risk of death in patients with one nosocomial infection was 7.5%, and in patients developing more than one nosocomial infection was 17.1%. After adjusting for several confounding variables, the development of an organ/space surgical site infection was significantly related to mortality (OR = 4.5, 95% CI 1.5-15.6) as was blood infection (OR = 17.3, 95% CI 3.5-87.0). The association of a surgical site infection and either a respiratory tract infection or a blood infection also increased significantly the risk of in-hospital mortality (OR = 3.3, 95% CI 1.2-8.7). In conclusion, the NNIS index is a good predictor of in-hospital mortality. Patients developing an organ/space surgical site infection and/or a blood infection have an increased risk of in-hospital mortality.

The effect of frequency of chart review on the sensitivity of nosocomial infection surveillance in general surgery.

OBJECTIVE: To assess the sensitivity of different frequencies of nosocomial infection surveillance (NIS) in general surgery. DESIGN: Data obtained with a prospective daily NIS are compared with those of hypothetical cross-sectional studies carried out with different frequencies (from one weekly visit up to one visit every other day). SETTING: General surgery services at three hospitals. MAIN OUTCOME MEASURE: Sensitivity in the detection of nosocomial infection (overall and stratified by site), compared to a gold standard of prospective surveillance of every patient's complete medical record daily from the first day after surgery until discharge and once more after discharge. PATIENTS: 5,859 patients. RESULTS: 837 nosocomial infections were detected by the gold standard (58.8% were surgical-site infections [SSI]). The sensitivity of weekly NIS for all infections was 74.5% (95% confidence interval [CI95], 71.4%-77.5%) and varied from 65.1% (CI95, 56.2%-73.3%) for urinary tract infection to 83.3% (CI95, 62.6%-95.3%) for respiratory tract infection; it was 76.4% (CI95, 72.4%-80.1%) for SSI. As expected, sensitivity increased with the frequency of NIS. Performing NIS every 4 days improved sensitivity significantly, to 82.3% (CI95, 79.5%-84.8%) for all infections and 83.3% (CI95, 79.7%-86.5%) for SSI. One visit every other day increased the sensitivity for all infections by another 4.9%, mainly due to increased detection of urinary tract and other less severe infections. CONCLUSIONS: The sensitivity of two visits a week exceeded that of one weekly visit by approximately 8%, and one visit every other day added another 5% increase. Results varied according to duration of infection and postdischarge hospital stay.