Improvements in the Management of Patients With Generalized Pustular Psoriasis in Spain: Recommendations From a Group of Experts. / Mejoras en la atención al paciente con psoriasis pustulosa generalizada en España: recomendaciones de un grupo de expertos.

This consensus document analyzed the management and emotional journey of patients with GPP (generalized pustular psoriasis), and the desirable course of the disease while detecting critical points and translating them into needs and recommendations. This project was conducted in 3 phases with participation from an advisory committee (n=8), an expert panel (n=15) and patients with GPP (n=6). The patients' disease progression was heterogeneous due to disease variations, different health care models implemented and available resources, and the lack of diagnostic and treatment guidelines. A total of 45 different recommendations have been made to optimize management and address the emotional component of these patients. Five of them stand out for their impact and viability. Therefore, a roadmap of priorities has been made generally available to improve the management of patients with GPP.

12 Years of Repair of Amalgam and Composite Resins: A Clinical Study.

OBJECTIVE: The objective of this study was to clinically evaluate repaired posterior amalgam and composite restorations over a 12 year period, investigate the influence of repair in the survival of restorations, and compare their behavior with respect to controls. METHODS: Thirty-four patients, 18 to 80 years of age with 167 restorations, 67 composite resin (RC), and 100 amalgam (AM) restorations, participated. Restorations with localized, marginal, anatomical deficiencies and/or secondary caries, and "clinically judged" suitable for repair or replacement according to US Public Health Service (USPHS) criteria, were randomly assigned to four groups: repair (n=35, 20 AM, 15 RC), replacement (n=43, 21 AM, 22 RC), positive control (n=71, 49 AM, 22 RC), or negative control (n=18, 10 AM, 8 RC). The quality of the restorations was blind scored according to the modified USPHS criteria. Two examiners scored them at initial status (κ=0.74) and after one to five, 10, and 12 years (κ=0.88). Wilcoxon and Mann-Whitney tests provided for comparisons within the same group and between years, respectively. RESULTS: After 12 years, all groups behaved similarly in marginal adaptation, marginal stain, teeth sensitivity, anatomic form, and luster ( p≥0.05). Better behavior in roughness was observed in replaced RC ( p=0.049). CONCLUSIONS: Given that most clinical parameters investigated were similar between all groups during the follow-up, the repair of RC and AM restorations is a good clinical option because it is minimally invasive and can consistently increase the longevity of restorations.

Experiencia preliminar en el uso del registro de fertilidad en una cohorte de pacientes de infertilidad en un servicio de ginecología y obstetricia / Preliminary experience in the use of fertility charting in a cohort of infertility patients at a department of obstetrics and gynecology / Experiência preliminar no uso do registro de fertilidade em um coorte de pacientes de infertilidade num serviço de ginecologia e obstetrícia

Objetivo: estudiar los resultados de las pacientes con infertilidad tratadas con un enfoque de medicina restaurativa (naprotecnología) en un servicio de ginecología y obstetricia. Metodología: estudio de cohorte retrospectivo realizado por el departamento de obstetricia y ginecología de la Universidad de los Andes (Santiago, Chile) en pacientes con infertilidad de un área suburbana de Santiago de Chile, que recibieron tratamiento entre el 2006 y 2014. Todas las parejas recibieron instrucción para reconocer su período de fertilidad según un modelo local de enseñanza, basado en el modelo Creigthon (Creigthon Model FertilityCare System). Recibieron, además, tratamiento médico para inducción de ovulación, mejoramiento del período fértil o cirugía reparadora. La medición primaria fue el número de embarazos. Resultados: 131 pacientes recibieron la instrucción. El promedio de edad fue de 33.6 años. 78 pacientes (59.5%) consultaron por infertilidad primaria; 53 (40.5%), infertilidad secundaria. El tiempo de infertilidad del grupo fue de 4.1 años. El promedio de uso del método fue de 12.6 meses (mediana, 9 meses). Las causas de infertilidad identificadas fueron anovulación (50.4%), tubo-peritoneal (18.3%), endometriosis (14.5%), uterino (9.2%), cervical (8.4%) y masculino (19.1%). Hubo 33 embarazos (25.2 global). La proporción cruda de embarazos a los 24 meses fue de 22.9% y la ajustada por tabla de vida a los 24 meses fue de 40 por 100 parejas. Conclusiones: el enfoque de medicina restaurativa es efectivo para lograr embarazos pero requiere de un manejo longitudinal a largo plazo. El abandono temprano del uso del registro de fertilidad afecta la eficacia del enfoque. Se requiere de mayor investigación para optimizar el manejo médico.

Objective: to study the results in patients undergoing infertility treatment with a focus on restorative medicine (NaProTechnology) at a department of obstetrics and gynecology. Methodology: retrospective cohort study conducted by the gynecology and obstetrics department at Universidad de los Andes (Santiago, Chile) in infertility patients from a suburban area of Santiago de Chile, who received treatment between 2006 and 2014. All couples received instructions on how to recognize their fertility period according to a local teaching model based on the Creighton Model FertilityCare System. They also received medical treatment to induce ovulation and/or widen their fertile period, or surgical treatment. The main outcome was the number of pregnancies. Results: 131 patients received instructions. The mean age was 33.6 years. Seventyeight patients (59.5%) consulted due to primary infertility; 53 (40.5%) due to secondary infertility. The duration of group infertility was 4.1 years. The mean use of the method was 12.6 months (median, 9 months). The infertility causes identified included anovulation (50.4%), tubo-peritoneal factors (18.3%), endometriosis (14.5%), uterine factors (9.2%), cervical factors (8.4%) and masculine factors (19.1%). There were 33 pregnancies (25.2 global). The crude proportion of pregnancies at 24 months was 22.9% and the proportion adjusted by the life table at 24 months was 40 per 100 couples. Conclusions: the focus on restorative medicine is effective to achieve pregnancy but it requires a long-term longitudinal treatment. Early discontinuation of fertility charting affects the efficacy of this focus. More research is warranted to optimize medical treatment.

Objetivo: estudar os resultados das pacientes com infertilidade tratadas com um enfoque de medicina restaurativa (naprotecnologia) em um serviço de ginecologia y obstetrícia. Metodologia: estudo de coorte retrospectivo realizado pelo departamento de obstetrícia e ginecologia da Universidad de los Andes (Santiago, Chile) em pacientes com infertilidade de uma área suburbana de Santiago de Chile, que receberam tratamento entre 2006 e 2014. Todas os casais receberam instrução para reconhecer seu período de fertilidade segundo um modelo local de ensinamento, baseado no modelo Creigthon (Creigthon Model FertilityCare System). Receberam, ademais, tratamento médico para indução de ovulação, melhoramento do período fértil ou cirurgia reparadora. A medição primária foi o número de gravidez. Resultados: 131 pacientes receberam a instrução. A média de idade foi de 33.6 anos. 78 pacientes (59.5%) consultaram por infertilidade primária; 53 (40.5%), infertilidade secundária. O tempo de infertilidade do grupo foi de 4.1 anos. A média de uso do método foi de 12.6 meses (mediana, 9 meses). As causas de infertilidade identificadas foram anovulação (50.4%), tubo-peritoneal (18.3%), endometriose (14.5%), uterino (9.2%), cervical (8.4%) e masculino (19.1%). Houve 33 gravidezes (25.2 global). A proporção crua de gravidezes aos 24 meses foi de 22.9% e a ajustada por tabela de vida aos 24 meses foi de 40 por 100 casais. Conclusões: o enfoque de medicina restaurativa é efetivo para conseguir gravidezes mas requere de um manejo longitudinal a longo prazo. O abandono precoce do uso do registro de fertilidade afeta a eficácia do enfoque. Se requere de maior investigação para otimizar o manejo médico.

[Blood transfusion during heart surgery. A retrospective nested case-control study]. / Transfusión intraoperatoria en cirugía cardiaca. Estudio retrospectivo anidado de casos y controles.

OBJECTIVE: To assess the correlation between intraoperative packed red blood cells transfusion and adverse outcome in a Spanish cohort of cardiac surgery patients. METHODS: Retrospective observational multicentre study. An analysis was performed on the data from 927 cardiac surgery patients treated in 24 Spanish hospitals in 2007. Patients who received intraoperative transfusions were compared with non-transfused patients. Multivariate analyses were performed (including, among others, several items from the Euroscore, surgery type, basal renal status and haemoglobin levels, and Thakar score). RESULTS: Every transfusion of packed red cells was associated with increased postoperative risk of acute kidney damage at 72 hours after surgery, prolonged mechanical ventilation, and need for haemodynamic support. Moreover, transfused patients showed an increased in-hospital mortality rates (Adjusted OR: 1.30; 95% CI: 1.19-1.42), as well as longer hospital stays (almost 4 days). CONCLUSIONS: In this cohort of patients, intraoperative transfusion might independently predict higher risk of early acute kidney damage, prolonged postoperative mechanical ventilation, and a need for haemodynamic support, and reduced short term survival (adjusted OR for mortality: 1.30; 95% CI: 1.19-1.42), and longer hospital stays (4 days longer).

[Resuscitation damage control in the patient with severe trauma]. / Reanimación de control de daños en el paciente adultocon trauma grave.

Severe trauma is the principle cause of death among young people in developed countries, with the main causes being due to road traffic accidents and accidents at work. The principle cause of death in severe trauma is the massive uncontrolled loss of blood. Most of the severe traumas with a massive haemorrhage develop coagulopathy, with some controversy over what is the best treatment for this. Patients with severe trauma are complex patients; they have a high mortality, they consume a significant amount of sources and can require rapid, intensive and multidisciplinary treatment encompassed within the concept of resuscitation damage control. In this article we attempt to present a current view of the pathophysiology of severe trauma and resuscitation damage control that may be applied to these types of patients.

[Acute kidney injury]. / Insuficiencia renal aguda.

Acute kidney injury (AKI) is defined as an abrupt decline in the glomerular filtration rate with accumulation of nitrogenous waste products and the inability to maintain fluid and electrolyte homeostasis. Occurring in 7% of all hospitalized patients and 28% to 35% of those in intensive care units, AKI increases hospital mortality. Early evaluation should include differentiating prerenal and postrenal components from intrinsic renal disease. Biological markers can give early warning of AKI and assist with differential diagnosis and assessment of prognosis. The most effective preventive measure is to maintain adequate circulation and cardiac output, avoiding ischemia- or nephrotoxin-induced injury. To that end, patients and situations of risk must be identified, hemodynamics and diuresis monitored, hypovolemia reversed, and nephrotoxins avoided. Protective agents such as sodium bicarbonate, mannitol, prostagiandins, calcium channel blockers, N-acetyl-L-cysteine, sodium deoxycholate, allopurinol, and pentoxifylline should be used. Treatment includes the elimination of prerenal and postrenal causes of AKI; adjustment of doses according to renal function; avoidance of both overhydration and low arterial pressure; maintenance of electrolytic balance, avoiding hyperkalemia and correcting hyperglycemia; and nutritional support, assuring adequate protein intake. For severe AKI, several modalities of renal replacement therapy, differentiated by mechanism and duration, are available. Timing--neither the best moment to start dialysis nor the optimal duration--has been not established. Early detection of AKI is necessary for preventing progression and starting renal replacement therapy at adjusted doses that reflect metabolic requirements.

[An awake fiberoptic intubation protocol: descriptive retrospective assessment of safety and efficacy]. / Evaluación de la eficacia y seguridad de un protocolo de intubación mediante fibroscopio en paciente despierto. Estudio descriptivo retrospectivo.

BACKGROUND AND OBJECTIVE: Flexible fiberoptic intubation of the trachea is emphasized in guidelines on the management of difficult airway. The aim of this study was to analyze the efficacy and safety of our tertiary hospital's awake fiberoptic intubation protocol. MATERIAL AND METHODS: For retrospective descriptive study we collected information on all fiberoptic intubations performed on awake patients in the 3 years after a specific protocol was implemented. The protocol's key points focus on operating room arrangement, required staff, and sedation before the procedure. Data gathered included demographic variables, patients' diseases, preanesthetic assessment of potential difficult airway, adherence to the protocol, medication administered, and complications recorded. RESULTS: In the course of the study, 634 fiberoptic intubations were performed; 473 patients (74.6%) had at least 1 risk factor for aspiration and 232 patients (36.5%) had at least 1 type of cardiovascular comorbidity. Difficult intubation was expected in 67%. In 99%, remifentanil was administered via target controlled infusion with a mean effect concentration of 2.9 ng/mL. The operating room arrangement and staffing protocol was followed in all cases. No pulmonary or hemodynamic complications occurred during fiberoptic intubation or immediately after surgery. CONCLUSION: Our hospital's protocol was followed in all cases and no post-implementation complications were detected.

Estabilidad de haloperidol-butilescopolamina-midazolamen sistemas de infusión continua de 24 horas / No disponible

Objetivo: determinar la estabilidad de la mezcla ternaria haloperidolbutilescopolamina-midazolam para establecer su validez terapéutica. Material y método: se estudiaron mezclas ternarias de haloperidol, butilescopolamina (Br), y midazolam, utilizando como vehículo glucosa 5%, a concentraciones de 0,2 y 0,8 mg/ml para haloperidol. Para los otros dos componentes la concentración (1,2 mg/ml) permaneció invariable. El estudio se realizó bajo condiciones asépticas, a temperatura ambiente, sin fotoprotección, por duplicado y durante un periodo de 84 horas. Como criterios de compatibilidad física: cambio de color, aparición de opalescencia, variación de peso y pH. La estabilidad química de los componentes se evaluó mediante cromatografía líquida de alta resolución ultravioleta-visible. Como parámetro de validez clínica se empleó el T90, considerando para su cálculo el valor obtenido al interpolar el límite inferior del intervalo de confianza del 95% de la recta representativa de la cinética lineal, para una concentración del 90% de la concentración inicial de los componentes. Resultados: los valores de las concentraciones de los componentes se ajustaron a una cinética de orden uno. El valor de T90 obtenido no fue inferior a 72 horas en las mezclas estudiadas. Durante las 84 horas que duró el ensayo ninguna de las mezclas presentó cambio de color, aparición de opalescencia, variación de peso ni de pH. Conclusión: las mezclas intravenosas a las concentraciones estudiadas de haloperidol (hasta 0,8 mg/ml), butilescopolamina (Br) (1,2 mg/ml) y midazolam (1,2 mg/ml), preparadas en glucosa 5%, en sistemas de infusión elastoméricos portátiles, son físicamente compatibles y químicamente estables durante al menos 72 horas (AU)

Objective: to determine the stability of ternary mixtures of haloperidol, midazolam, and scopolamine in order to establish their therapeutic validity. Material and methods: ternary mixtures of haloperidol, scopolamine, and midazolam were prepared in 5% glucose as vehicle at concentrations of 0.2 and 0.8 mg/mL for haloperidol. Concentration (1.2 mg/mL) remained invariable for the other two components. The study was conducted under aseptic conditions, at room temperature, without photoprotection, in duplicate, and during a period of 84 hours. Chemical stability was evaluated by high pressure liquid chromatography, and physical compatibility by changes in colour, development of opalescence, and changes in weight and pH. The T90 parameter was used to establish clinical validity, and was calculated for each drug in the mixture by considering the time at which the 95% one-sided confidence limit for the mean curve intersects 90% of the drug's initial concentration. Results: concentrations were adjusted to a first-order kinetic equation. The value of T90 was obtained after no less than 72 hours in the mixtures studied. During the 84-hour test none of the mixtures developed changes in colour, opalescence, or changes in weight or pH. Conclusion: the intravenous mixtures studied, consistent of haloperidol (up to 0.8 mg/mL), scopolamine (1.2 mg/mL), and midazolam (1.2 mg/mL) prepared in 5% glucose within elastomeric portable infusion systems, are physically compatible and chemically stable for at least 72 hours (AU)

Gestión de la calidad en nutrición parenteral. Prevalencia de hiperglucemia en pacientes con nutrición parenteral total / Quality management in parenteral nutrition. Prevalence of hyperglycemia among patients with total parenteral nutrition

No disponible

No disponible

[Experimental advances in mineral metabolism]. / Avances experimentales en metabolismo mineral.

One of the most important problems faced by nephrologists is the high degree of cardiovascular mortality in patients on dialysis. This increase in cardiovascular disease has been associated with various factors, but, among them, hyperphosphatemia stands out particularly. The serum phosphate levels considered normal in these patients have gradually decreased in recent years. Therefore, phosphate control in the chronic kidney disease patient has become a challenge that has stimulated basic research in recent years. The aim of the following review is to bring together the most novel results presented in the last year, with emphasis on the methods for control of phosphate absorption, its elimination by the kidneys and vascular calcifications, which are one of the most serious direct consequences of hyperphosphatemia.

Incorporación de la Troponina T en la evaluación extrahospitalaria del dolor torácico / Incorporation of Troponin T in the pre-hospital evaluation of chest pain

Objetivo: La determinación de marcadores de daño miocárdico es un importante elemento diagnóstico y pronóstico en el manejo del dolor torácico. El presente trabajo pretende evaluar la viabilidad de la determinación extrahospitalaria de Troponina T (TnTc), así como su relación con el diagnóstico y el pronóstico de los pacientes. Métodos: Se incluyeron pacientes mayores de 25 años atendidos por dolor torácico agudo en servicios de emergencias extrahospitalarios. Además de variables clínicas, se realiza electrocardiograma y determinación cuantitativa de TnTc (TnTc- < 0,05 ng/ml, TnTc+ 005-0,1 ng/ml y TnTc++ igual o mayor a 0,1 ng/ml). Se realiza seguimiento al ingreso y a los seis meses. Análisis descriptivo y de supervivencia. Resultados: Un total de 597 pacientes fueron incluidos en el análisis final. La edad media fue 66 años, y el 61,3 por ciento fueron hombres. La determinación de TnTc fue positiva en 71 casos (11,9 por ciento). El diagnóstico final fue de Infarto Agudo de Miocardio (IAM) o de Angina Inestable (AI) en 60 de los 71 (84,5 por ciento) pacientes. En los primeros seis meses fallecieron 53 (8,9 por ciento) de los 597 pacientes. De ellos 19 tuvieron TnTc positiva (5 TnTc+ y 14 TnTc++).La mortalidad a los seis meses fue significativamente más alta en los pacientes de mayor edad, o en aquellos con TnTc positiva o con diagnóstico hospitalario de IAM o de AI. La TnTc se comportó como variable independiente predictora de mortalidad. Conclusiones: La determinación cuantitativa de TnTc es factible en el medio extrahospitalario y, aunque tiene una baja sensibilidad, permite disponer de un dato objetivo que se relaciona directamente con el diagnóstico final y con el pronóstico de los pacientes (AU)

[Evaluation of a formula for optimal positioning of a central venous catheter through the right internal jugular vein]. / Evaluación de una fórmula para la posición óptima de un catéter venoso central a través de vena yugular interna derecha.

OBJECTIVE: To evaluate the efficiency of a formula for predicting the optimal length of catheter inserted through the right internal jugular vein. PATIENTS AND METHOD: A prospective study in which the length of catheter to insert was calculated by the following formula: (height in cm/10)-1 cm. Punctures were approximately at the cricoid cartilage and length was measured from the point of insertion. Catheter tip placement was confirmed by anteroposterior chest film, read by a radiologist blinded as to the objective of the study. The position was considered optimal if the catheter tip was in the distal portion of the superior vena cava. Patients enrolled required insertion of a central venous line for therapy or monitoring and were excluded if they had risk factors that could predispose them to poor placement. RESULTS: Fifty-eight catheterizations were performed. Three of them were excluded due to poor positioning in the contralateral subclavian vein. Among the 55 remaining patients, we observed the catheter tip in the superior vena cava in 52 cases and in the right atrium in 3. CONCLUSIONS: The aforementioned formula predicted appropriate placement of the catheter tip in 94.54% of the patients.