Midterm Results of Renal Transplantation From Controlled Cardiac Death Donors Are Similar to Those From Brain Death Donors.

BACKGROUND: The systematic use of grafts from controlled donors after cardiac death (cDCD) started in our country in 2012 and expanded with the strategic support of National Transplant Organization. We present our experience in kidney transplantation with organs from cDCD donors with a mean follow-up of 3 years. METHODS: Observational prospective study of all transplants performed in our center in 2012-2013 followed to 2016. The immunosuppression protocols were triple therapy for low-risk recipients from a standard brain death donor (DBD), adding basiliximab or thymoglobulin induction for extended-criteria donor or high-risk recipient, respectively, and thymoglobulin induction plus triple therapy for all cDCD recipients. RESULTS: A total of 42 donors were included (84 grafts in total, but 1 discarded due to multiple cysts); 25 DBD and 17 cDCD without differences in age or sex. The graft use rate was 98.9% for cDCD; 55 grafts were implanted in our hospital (26 DBD and 29 cDCD), and the remaining 28 grafts were transferred to other centers. There were no differences in primary failure (3.4% cDCD vs 7.4% DBD), but the cDCD organs had a higher incidence of delayed graft function (51.7% vs 25.9%). Despite that, graft and patient survivals, as well as glomerular filtration rate (66.3 vs 59.6 mL/min) were similar in both groups. Only 1 patient died at home with a functioning graft in the cDCD group. CONCLUSIONS: Despite a higher rate of delayed graft function with cDCD, the midterm outcomes are at least similar to those with DBD. The cDCD programs should be promoted to increase the chances of a transplant in our patients.

[Programme to overcome tobacco dependency in cases of scheduled surgery]. / Programa de deshabituación tabáquica en cirugía programada.

INTRODUCTION AND OBJECTIVES: Tobacco dependency is now beginning to be seen as a chronic disease. The scientific evidence of the damage it causes and the existence of efficient interventions mean it has to be tackled. In Health Area VIII of Asturias a plan to aid smokers was initiated in 1998. Now we want to extend this to patients who are going to have scheduled surgery, since it has been demonstrated that tobacco increases post-operative complications. In addition, having to confront surgery may be a reason for trying to give up tobacco. ACTIVITIES: Patients who are going to undergo surgery will be questioned and counselled on their tobacco habit during the pre-operative period. They will do the Richmond test and will be referred to the health centre if their score is >= 7.Interventions. The family doctor assesses the smokers' dependency and motivation, and offers them personalised treatment to give up. During their time in hospital, a nurse backs up their non-smoking. Once discharged, they are monitored periodically in primary care. EVALUATION: At the same time as the annual evaluation of the service portfolio, the number of smokers who underwent surgery and were counselled, visited on the ward and monitored in primary care will be measured. The number of patients still not smoking at one month, six months and twelve months will be recorded. CONCLUSIONS: Lack of finance for the treatment may be one of the limitations of the programme. Although there are experiences in other countries of interventions in smokers who are going to have surgery, we have found no similar programme here.

Marco para el desarrollo de modelos de gestión en centros sanitarios / Setting for the development of management models in health care centers

Plantearnos la situación actual de los sistemas de gestión implantados actualmente en los hospitales, nos sugiere la necesidad de evaluarlos desde una perspectiva histórica. En este primer artículo, básicamente teórico, trataremos esa evolución, intentando llegar a la situación actual a través de las distintas contribuciones realizadas por los profesionales que los han desarrollado, para posteriormente intentar aplicar un modelo de determinación de costes por procesos que asimile todas las contribuciones realizadas a lo largo de la vida de los hospitales, tanto a nivel clínico como económico (AU)

[Length of temporal disability caused by tuberculosis]. / Duración de la incapacidad temporal por tuberculosis.

OBJECTIVE: To determine the average length of time off work in working persons ill with tuberculosis in a health district. DESIGN: Descriptive and retrospective. SETTING: Community level, within a health district. PARTICIPANTS: Persons diagnosed between 1989 and 1998 with tuberculosis which caused time off work. MEASUREMENTS AND MAIN RESULTS: An epidemiological data base of people with tuberculosis was crossed with the time-off-work records of the district's medical inspectorate, producing 58 patients. Average time off work was 220.3 days. Mean age was 37, almost all men (93.1%). 36.2% of the workers were miners, with their time off work greater than other workers (p = 0.003). No significant differences in the length of time off work were found for the variables of age, sex, health district, type of tuberculosis or year of diagnosis. CONCLUSIONS: We found that time off work lasted much longer than is customary, and was related to the hardship of the physical work. Return to work should be posed when there is clinical improvement in the patient and a definitive response to the tuberculosis treatment.

[Study of medical-legal consultations outside the health system in primary care]. / Estudio de las consultas médico-legales ajenas al sistema sanitario en atención primaria.

OBJECTIVE: To evaluate how consultations in order to obtain a medical/legal document, whose destination is other than the health service. DESIGN: A descriptive, crossover study, using a questionnaire filled in by the doctor at the time of the medical-legal consultation. PATIENTS AND OTHER PARTICIPANTS: All those users who attended in one year the clinics of the doctors taking part in the study, in order to seek a medical-legal document (MLD) whose destination was other than the health service. MEASUREMENTS AND MAIN RESULTS: Between 1-9-93 and 31-8-94 there were 287 consultations for a MLD. Of the variables studied, most attendances were by the age group between 15 and 44, masculine, with schooling up to EGB level (basic) or lower and unemployed or pensioner. Average length of the consultation was 6.6 minutes. 42.5% had a clinical interview. 4.6% were referred to a specialist. In 77.7% of cases, a document belonging to the health service was issued. The reason for the procedure was: health certificate (40%), and a sick note (39%). CONCLUSIONS: The PC doctor normally receives a considerable number of visits to obtain this kind of document, which are required by official bodies to determine the health status of users or concede social benefits to them. There are gaps in the rules on what kind of document.

[A sociodemographic study of pregnant women and relation to pregnancy acceptance]. / Estudio sociodemográfico de las gestantes y su relación con la aceptación del embarazo.

BACKGROUND: Control of normal pregnancy in the scope of primary Health care has been implemented recently; this is the reason why, many factors which have an influence on the use of this service, still remain unknown. We carried out this descriptive study in two Primary Health Care Centers of the VIII Health Area in Asturias, in order to approach the pregnant woman's profile from our primary health care centers, and to study the relation between pregnancy acceptance and sociodemographic characteristics. METHODS: The social histories of all women, who requested health care for their pregnancy during 1991, were collected; the most interesting sociodemographic variables and those ones directly related to pregnancy were obtained. RESULTS: Out of a total of 139 women, the mean age was 0.4 0.0006. There is a 16% of unmarried women. In relation with the pregnancy acceptance or desire, it was found that 31% of women did not desire it and this rejection was greater among unmarried women, younger than 20 years, (p = 0.0002) among those ones, whose contraceptive method had failed, (p = 0.0000) and among those ones, whose relations with their family were bad or not good enough (p = 0.0004). CONCLUSIONS: A pregnant woman's profile, from our health centers, is obtained. It is necessary to develop health education programmes and family planning in the groups of women with higher number of not desired pregnancies, (young unmarried women).

[Effects of high-frequency ventilation on the intracranial pressure and cerebral elastance in dogs]. / Efectos de la ventilación a alta frecuencia sobre la presión intracraneal y elastancia cerebral en perros.

We have evaluated the effects of the high frequency "jet" ventilation (HFJV) in 12 healthy dogs, under normal intracranial pressure (ICP) as well as under progressive Intracranial Hypertension (ICH). With a normal ICP, no significant differences were found in the mean ICP regarding the intermittent positive pressure ventilation (IPPV). However, during ICH the HFJV not only decreases the global cerebral elastance (CE), P/V curve with smaller slope, but also places the brain in an improved dynamic condition in the sense that, at an equal ICH level, the CE is lower, CE mean ICP relation having a significant difference (p less than 0.001).

Prognostic assessment of the acute complications of bone marrow transplantation requiring intensive therapy.

Patients with bone marrow transplant may present with acute, life-threatening complications which frequently (40% of our cases) require intensive care unit treatment and result in an increased mortality (76% in this series). In an attempt to reach a more objective prognostic assessment, we have analyzed those factors related to the worst outcome in the 25 patients with bone marrow transplant admitted into our intensive care unit. Respiratory failure was the most frequent complication (72%), with an 83% mortality. Graft-versus-host disease and neutropenia led to a greater number of infectious complications with a poor outcome. Failure of more than three organ systems, septic shock and mechanical ventilation were statistically associated with mortality (p less than 0.05), and all patients who required mechanical ventilation for more than seven days or needed intensive therapy for more than 10 days died. The presence of septic shock, multisystem failure and severe neutropenia on admission should be considered as initial indicators of a poor prognosis. More than 7 days of mechanical ventilation and an intensive care unit stay of more than 10 days could be critical points in the reassessment of the intensity and prolongation of treatment.

Effects of high-frequency jet ventilation on intracranial pressure and cerebral elastance in dogs.

In order to assess the effect of high-frequency jet ventilation (HFJV) on intracranial pressure (ICP) and cerebral elastance (CE), a model of progressive intracranial hypertension was developed. Six healthy dogs were ventilated using HFJV and another six with conventional mechanical ventilation. ICP and its pulse amplitude (Amp) were measured by means of an epidural transducer, and CE was assessed by analysis of the relationship between the Amp and the mean ICP. The mean ICP, under basal conditions, did not differ between the two forms of ventilation, the Amp and the slope of the relationship Amp/ICP being lower with HFJV (p less than .001). Since the lower airway pressure created with HFJV was the only difference, it is suggested that the differences found in this study are related to these pressures.

Early evaluation of coagulase negative staphylococcus in blood samples of intensive care unit patients. A clinically uncertain judgement.

Of 2160 intensive care unit patients, 36 patients with positive blood cultures had coagulase-negative staphylococcus in one blood bottle, whereas the organism was present in two or more bottles in 38 cases. The groups were not significantly different in 27 clinical variables, obtained at the time of their first positive blood culture. There was also no significant difference in the antimicrobial sensitivities. No initial clinical data supported the classification of coagulase-negative staphylococcus as either pathogen or contaminant. When the 74 patients with blood culture positive coagulase-negative staphylococcus were compared with three "control groups" ("absent septicemia," "probable septicemia" and "proven septicemia") they were not different from those with "probable septicemia." A discriminant analysis was performed comparing patients with "absent septicemia" and with "proven septicemia" in an attempt to classify patients with isolates of coagulase-negative staphylococcus in one of these groups at an early stage. Patients with two or more positive blood cultures were not statistically classified more frequently as septicemic than patients with one blood bottle positive for this organism. However, patients categorized as septicemic had a significantly higher mortality (59%) than those classified as non-septicemic (35%) (p less than 0.05).

Simple and accurate monitoring of end-tidal carbon dioxide tensions during high-frequency jet ventilation.

To determine whether end-tidal carbon dioxide tension (PETCO2) accurately reflects PaCO2 during high-frequency jet ventilation (HFJV), 43 studies were performed on eight mongrel dogs with normal lungs. During HFJV, minute volume was modified to obtain a range of PaCO2 values from 15.5 to 74.5 torr. When PETCO2 was measured with an infrared gas analyzer, there was a poor correlation between PaCO2 and PETCO2 values. However, when the high-frequency ventilator was adjusted to deliver large tidal-volume (sigh) breaths, PETCO2 values were significantly (r = 0.94, p less than .001) correlated with PaCO2. Our data suggest that the PETCO2 of alveolar gas is an accurate indicator of the PaCO2 during HFJV in nondiseased lungs.

Prolonged high-frequency jet ventilation in a patient with bronchopleural fistula. An alternative mode of ventilation.

We report a case of bronchopleural fistula (BPF) in a patient submitted to conventional mechanical ventilation in which high frequency jet ventilation (HFJV) was applied during five consecutive days. Gas exchange was adequate, the bronchial secretions could easily be cleared and the patient adapted comfortably to HFJV. In spite of PEEP levels between 4 and 8 mm Hg, the leak through the BPF ceased completely.

Septicaemia in a medical intensive care unit. Clinical, biochemical and microbiological data of 109 cases.

Blood cultures were obtained from 39% of all 574 admissions to our Medical Intensive Care Unit. (ICU); in 109 (19%) a pathogenic organism was demonstrated. 45% of the septicaemias were detected within the first 48 h of ICU stay have been considered as "non ICU-acquired". Septicaemic patients were significantly older, had longer ICU stays and a higher mortality rate (62%) than non septicaemic patients (28%) (p less than 0.05). Gram negative organisms (69%) predominated over gram positive (29%) and Serratia marcescens and coagulase positive Staphylococcus were the most frequently isolated. Shock appeared in 32% and had an extremely high mortality (91%) and was associated with the presence of "multiple species septicaemia". Prior to the septicaemia the survivors differed from the fatalities only in the level of serum albumin; this was significantly lower in patients with gram negative in comparison with gram positive septicaemias and in patients who developed shock. Arterial, pulmonary artery and urinary catheters, and endotracheal devices were used frequently in these patients and were statistically associated with the presence of septicaemia. The airway was the most frequent possible source for the septicaemia.