Conciliación de la medicación: desde el ingreso hasta la atención primaria / Medication reconciliation: from admission to primary care

Objetivos. Implementar un circuito de conciliación de la medicación interniveles, integral y multidisciplinar en una organización sanitaria integrada. Medir las discrepancias detectadas en cada uno de los pasos estudiados. Método. Estudio de intervención, prospectivo y de un año de duración. La medicación se concilió en 3 momentos distintos del paso del paciente por el sistema sanitario: al ingreso en el hospital, al alta y cuando el paciente acudió a su médico de Atención Primaria. Se recogieron y resolvieron las discrepancias detectadas cada vez que se concilió la medicación, y se cuantificó el número total de medicamentos antes y después de cada proceso de conciliación. Resultados. Entre el 1 de noviembre de 2013 y el 30 de octubre de 2014 se concilió la medicación a 77 pacientes, 63% hombres, con una media de edad de 69,5 años. La media de discrepancias por paciente fue de 7,85 al ingreso, 3,67 al alta y 2,19 en Atención Primaria. Conclusiones. Este programa de conciliación de la medicación, además de detectar y resolver las discrepancias, ha sido un punto de partida para establecer nuevas vías de comunicación entre los diferentes profesionales sanitarios que han intervenido en el programa y difundir la cultura de seguridad dentro de la organización (AU)

Objectives. To implement a medication reconciliation circuit of inter-level, comprehensive and multidisciplinary approach in an integrated health organization. To measure the discrepancies detected in each of the steps studied. Method. A prospective intervention study of one-year duration. The medication is reconciled at admission to the hospital, at discharge and when the patient goes to his Primary Care physician. The number and type of discrepancies detected each time the medication is reconciled are collected and resolved, as well as the total number of drugs before and after each reconciliation process quantified. Results. Between November 1, 2013 and October 31, 2014 the medication had been reconciled to 77 patients, 63% male, mean age 69,5 years. Mean admission discrepancy per patient was 7,85, 3,67 at discharge and 2,19 at Primary Care. Conclusions. This program of medication reconciliation, in addition to detect and resolve discrepancies, has been a starting point for establishing new channels of communication between the different health professionals who have participated in the program and disseminate the safety culture within the organization (AU)

[Medication reconciliation: From admission to primary care]. / Conciliación de la medicación: desde el ingreso hasta la atención primaria.

OBJECTIVES: To implement a medication reconciliation circuit of inter-level, comprehensive and multidisciplinary approach in an integrated health organization. To measure the discrepancies detected in each of the steps studied. METHOD: A prospective intervention study of one-year duration. The medication is reconciled at admission to the hospital, at discharge and when the patient goes to his Primary Care physician. The number and type of discrepancies detected each time the medication is reconciled are collected and resolved, as well as the total number of drugs before and after each reconciliation process quantified. RESULTS: Between November 1, 2013 and October 31, 2014 the medication had been reconciled to 77 patients, 63% male, mean age 69,5 years. Mean admission discrepancy per patient was 7,85, 3,67 at discharge and 2,19 at Primary Care. CONCLUSIONS: This program of medication reconciliation, in addition to detect and resolve discrepancies, has been a starting point for establishing new channels of communication between the different health professionals who have participated in the program and disseminate the safety culture within the organization.

[Bacterial translocation associated with short bowel: role of ileocecal valve and cecum]. / La traslocación bacteriana asociada al intestino corto: papel de la válvula ileocecal y del ciego.

Sepsis in short bowel syndrome (SBS) is due in part to bacterial translocation (BT). Parenteral nutrition (PN) is often necessary in SBS and promotes BT. The presence of ileocecal valve (ICV) has been considered as a good prognostic factor in the outcome of this children. The aim of this study was to asses the effect of the presence or absence of ICV and cecum in five different models of gut resection in the rat. Fifty-five adult Wistar rats were randomly assigned to one of five groups: Group 1 (N = 14): standard rat chow + 80% small bowel resection. Group 2 (N = 10): standard rat chow + 80% small bowel resection including cecum. Group 3 (N = 10): standard rat chow + 80% small bowel resection including ICV. Group 4 (N = 11): NP + 80% small bowel resection. Group 5 (N = 10): NP + 80% small bowel resection including ICV and cecum. Ten days after surgery they were sacrificed and mesenteric lymph nodes (MLN), spleen and peripheral (PBL) and portal blood (POBL) specimens were recovered and cultured. Groups 3 (without ICV, with cecum) and 5 (without ICV, without cecum) showed 60% BT in MLN and POBL, and groups 1 and 4 (with ICV, without cecum) 93% and 91% respectively (p < 0.05). In PBL, group 3 (without ICV, with cecum) showed also less BT than groups 1 and 4 (10% vs 43% and 55% respectively, p < 0.05) and group 5 (without ICV and cecum) had less BT than groups 1, 2 and 4 (0% vs 43%, 30% and 55%, p < 0.01). In conclusion, these results suggest that the absence of ICV decreases BT and that the cecum does not seems to play a role on his.

[Effect of various trophic factors on bacterial translocation in experimental short bowel syndrome]. / Efecto de diferentes factores tróficos sobre la traslocación bacteriana en el síndrome de intestino corto experimental.

Massive bowel resection triggers an adaptive process in the remaining intestine in spite of which, bacterial translocation (BT) is frequent under these conditions. Several trophic factors, including growth hormone (GH), epidermal growth factor (EGF) and insuline (INS) are involved in the process of adaptation in short bowel syndrome (SBS). However, the effect of GH, EGF or INS on BT has not been investigated experimentally. The aim of the study was to test the hypothesis that GH, EGF or INS administration prevents BT in rats with SBS receiving only parenteral nutrition (PN). Thirty-seven adult Wistar rats underwent central venous cannulation and were randomly assigned to one of two groups receiving for ten days four treatment regimes: PN group (N = 10) fasting, all-in-one PN solution (300 mL/kg/24 h, 280 kcal/kg/24 h), 80% gut resection including ileo-cecal valve. GH group (N = 9) fasting, same PN regime and resection plus GH (1 mg/kg/d, s.c.). EGF group (N = 9): same PN regime and resection plus EGF (150 microgr/24 h, e.v.) INS group(N = 9): same PN regime and resection plus INS (1 U.I./100 g/24 h s.c.) At the end of the experiment the rats were exanguinated and mesenteric lymph nodes and samples of systemic and portal blood were obtained and cultured. Several samples of full-thickness jejunal wall were taken for measuring cell proliferation index (PCNA) and mucosal thickness. Jejunal mucosal thickness increased by 30%, 28% and 29% and PCNA index by 21%, 20% and 25% in GH, EGF and INS, treated rats respectively in comparison with those treated with PN alone. However, contrary to our expectations, BT expressed by positive culture of intestinal germs in systemic blood was demonstrated respectively in 44%, 40% and 28% of GH, EGF and INS animals, respectively, and in 0% of PN-only rats. Although exogenous GH, EGF or INS improves gut mucosal structure in rats with SBS treated with PN, it seems to increase rather than decrease mucosal permeability to intestinal germs in them.

La traslocación bacteriana asociada al intestino corto: papel de la válvula ileocecal y del ciego / Presentation of the ileocecal valve and cecum in experimental short bowel with total parentera nutrition and its effect on bacterial translocation

En el síndrome de intestino corto (SIC) es muy frecuente la aparición de sépsis, que puede ser debida a la traslocación bacteriana (TB). La nutrición parenteral (NP), tan a menudo necesaria, también favorece la aparición de TB. La conservación de la válvula ileocecal (VIC) se ha considerado siempre como un factor de buen pronóstico en el SIC. Por otro lado, la presencia o ausencia de ciego (como gran reservorio de bacterias) podría tener alguna influencia en la evolución de los niños con SIC. El objeto de este trabajo es estudiar el efecto de la presencia o ausencia de la VIC y de ciego sobre la TB, en cinco modelos diferentes de resección intestinal en la rata. Cincuenta y cinco ratas Wistar adultas fueron asignadas de manera aleatoria a uno de los siguientes cinco grupos: • Grupo I (N = I4): dieta oral + resección del 80 por ciento del intestino delgado.• Grupo 2 (N = 10): dieta oral + resección del 80 por ciento del intestino delgado incluyendo ciego.• Grupo 3 (N = 10): dieta oral + resección del 80 por ciento del intestino delgado incluyendo VIC.• Grupo 4 (N = I I ): NP + resección del 80 por ciento del intestino delgado. • Grupo 5 (N = 10): NP+ resección del 80 por ciento del intestino delgado incluyendo ciego y VIC. Tras diez días de permanencia en jaulas metabólicas, los animales fueron sacrificados y se tomaron muestras para cultivo de ganglios mesentéricos, sangre portal y sangre periférica. En ganglios mesentéricos y sangre portal, los grupos 3 (sin válvula, con ciego) 5 (sin válvula ni ciego) tuvieron un 6047 de TB, mientras que Ios grupos I y 4 (con válvula y ciego), 93 por ciento y 91 por ciento respectivamente (p < 0,05). En sangre periférica, el grupo 3 tuvo menos TB que los grupos I y 4 (10 por ciento vs 43 por ciento y 55 por ciento respectivamente: p < 0,05) y el grupo 5. menos que los grupos I, 2 y 4 (0 por ciento vs 4347. 30 por ciento y 55 por ciento respectivamente: p < 0,01). Estos datos sugieren que la ausencia de válvula ileocecal disminuye la TB en el intestino corto experimental y que el ciego, por el contrario, no parece tener ninguna influencia. (AU)

Efecto de diferentes factores tróficos sobre la traslocación bacteriana en el síndrome de intestino corto experimental / Effect of trophic factors on bacterial translocation in experimental short bowel syndrome

La traslocación bacteriana (TB) es frecuente tras la resección intestinal masiva, y una de las causas de mortalidad por sepsis en niños con síndrome de intestino corto (SIC). Aunque diversos factores tróficos han demostrado tener una acción positiva en el proceso de adaptación intestinal, su efecto sobre la TB en el intestino corto experimental no ha sitio aún investigado.El objeto de este estudio es poner a prueba la hipótesis de que la administración de hormona de crecimiento (GH), factor de crecimiento epidérmico ( EGF) o insulina (INS) disminuyen la TB en el intestino corto en ratas bojo nutrición parenteral (NP).A 37 ratas Wistar adultas se les colocó un catéter venoso central seguido de resección del 80 por ciento del intestino delgado incluyendo ciego y válvula ileocecal con anastomosis ileo-cólica término-terminal y se les asignó aleatoriamente a uno de los cuatro grupos siguientes: •Grupo NP (N=10): NP (300mL/kb/24h, 28() kcal/kg/24h), •Grupo GH (N=9): NP y 1 mg/kg/d subcutáneo de GH.•Grupo EGF (N=9): NP y EGF ( 150 microgr/24h, e.v.) •Grupo INS (N=9) : NI) e insulina S.C. (I U.I/100/kg/ 24h) Los animales fueron sacrificados mediante sangría tras diez días de evolución y se obtuvieron y cultivaron muestras de los ganglios linfáticos mesentéricos, sangre portal y sangre periférica. Se procesaron asimismo varios cortes de intestino para estudiar la proliferación celular (antígeno de proliferación celular nuclear, PCNA) y parámetros morfométricos (altura de las vellosidades, profundidad de las criptas).Los grupos GH, EGF e INS mostraron un aumento del 30 por ciento, 28 por ciento y 29 por ciento en el espesor de la mucosa y el índice de PCNA creció un 21 por ciento, 20 por ciento y 25 por ciento en relación al grupo NP. Crecieron gérmenes entéricos aerobios (E. Coli. Proteus o Klebsiella) en ganglios mesentéricos o sangre portal en el 60 por ciento de los animales del grupo NP, EGF e INS, y en 8/9 (89 por ciento) del grupo GH (p=0,07). Sin embargo, en sangre periférica no hubo TB en el grupo NP, mientras que en los demás fue del 44 por ciento, 40 por ciento y 28 por ciento, respectivamente (P<0,05 vS grupo NP).Estos resultados confirman que la administración de factores tráficos como GH, EGF o insulina mejoran la estructura de la pared intestinal en ratas con SIC bajo NP, pero, sorprendentemente, la incidencia de TB aumentó en los animales que fueron tratados con GH, EGF o insulina (AU)

Effect of growth hormone, epidermal growth factor, and insulin on bacterial translocation in experimental short bowel syndrome.

BACKGROUND/PURPOSE: An adaptive process starts in the remaining intestine after massive resection, and several trophic factors including growth hormone (GH), epidermal growth factor (EGF), and insulin (INS) have been shown to have a positive effect on it. Bacterial translocation (BT) is frequent after extensive small bowel resection, but the effects of GH, EGF, or INS have not been investigated in experimental short bowel syndrome (SBS). This study tests the hypothesis that GH, EGF, or INS decrease BT in SBS in rats with parenteral nutrition (PN). METHODS: Thirty-eight adult Wistar rats underwent central venous cannulation and were assigned randomly to 1 of 4 groups receiving for 10 days 4 treatment regimes: (1) PN group (n = 10): fasting, all-in-one PN solution (300 mL/kg/24 h, 280 kcal/kg/24 h), 80% gut resection including ileo-cecal valve; (2) GH group (n = 9): fasting, same PN regime and resection, GH (1 mg/kg/d, subcutaneously); (3) EGF group (n = 9): fasting, PN, resection, EGF (150 microg/24 h intravenously); (4) INS group (n = 9): fasting, PN, resection, INS (1 UI/100 g/24 h subcutaneously). At the end of the experiment they were killed, and mesenteric lymph nodes (MLN) and peripheral and portal blood samples were recovered and cultured. Several fragments of intestine were taken to determine cell proliferation (PCNA index) and morphometric parameters (villous height, crypt depth). RESULTS: GH, EGF, and INS groups showed a 28%, 29%, and 30% increase in gut mucosal thickness, and PCNA index rose 21%, 20%, and 25%, respectively in comparison with PN controls. Bacterial translocation to peripheral blood was detected in 0% of PN animals and in 44%, 40%, and 28% of GH, EGF, or INS rats, respectively (P < .05). No differences were found in BT in MLN or portal blood among groups. CONCLUSION: Administration of GH, EGF, or INS improves gut mucosal structure in rats with SBS under PN, but, surprisingly, the incidence of BT detected in peripheral blood was increased rather than decreased in animals receiving these treatments.

Bacterial translocation is favored by the preservation of the ileocecal valve in experimental short bowel with total parenteral nutrition.

Sepsis in short-bowel syndrome (SBS) is in part due to bacterial translocation (BT). Parenteral nutrition (PN) is often necessary in SBS and promotes BT. The aim of this study was to asses the effect of the presence or absence of ileocecal valve (ICV) on BT in parenterally-fed rats with massive intestinal resection. Sixty-five adult Wistar rats underwent central venous cannulations and were randomly assigned to one of five groups receiving for ten days five treatment regimes: Sham (n = 17) standard rat chow + i.v. saline. PN (n = 17) fasting + PN. Res-Sham (n = 10) standard rat chow + i.v. saline + 80% gut resection. Res-PN (n = 11) fasting, PN + 80% gut resection. Res-ICV-PN (n = 10) fasting, PN + 80% gut resection including ICV. At the end of the experiment they were euthanized and mesenteric lymph nodes (MLN), spleen and peripheral and portal blood specimens were recovered and cultured. BT was found in 47% of PN animals, 91% of Res-PN rats, 100% of Res-Sham group and 60% of Res-ICV-PN animals, but not in Sham ones. 97% of BT+ animals had positive cultures in MLN and/or portal blood, whereas germs beyond liver were detected in 30% of Res-Sham, 37% of PN, 50% of Res-PN and 0% of Res-ICV-PN rats. The present study confirms that both massive intestinal resection and PN promote BT. In addition, it shows that animals deprived of ICV have lower incidence of BT in this setting than those with it and that the germs do not reach in them peripheral blood in the same proportions as in ICV-intact animals. These results suggest that the presence of an intact ICV favor BT in parenterally-fed rats with massive intestinal resection.

Effect of growth hormone on bacterial translocation in experimental short-bowel syndrome.

Despite the adaptive process triggered in the remaining intestine by massive bowel resection, bacterial translocation (BT) is frequent under these conditions. Several trophic factors, including growth hormone (GH), are involved in the process of adaptation in short-bowel syndrome (SBS). However, the effect of GH on BT has not been investigated experimentally. The aim of this study was to test the hypothesis that GH administration prevents BT in rats with SBS receiving only parental nutrition (PN). Nineteen adult Wistar rats underwent central venous cannulation and were randomly assigned to one of two groups receiving for 10 days two treatment regimes: PN group (n = 10): fasting, all-in-one PN solution (300 ml. kg. 24 h, 280 kcal/kg. 24 h), 80% gut section including ileocecal valve; GH group (n = 9): fasting, same PN regime and resection plus GH 1 mg/kg s.c). At the end of the experiment, the rats were killed and mesenteric lymph nodes (MLN) and samples of systemic and portal blood were obtained and cultured. Several samples of full-thickness jejunal wall were taken for determining cell proliferation index (PCNA) and mucosal thickness. Jejunal mucosal thickness increased by 30% and PCNA index by 35% in GH-treated rats in comparison with those treated with PN alone. However, contrary to our expectations, BT expressed by positive culture of intestinal flora in portal blood, MLN, or systemic blood was found in 60% of PN and 87% of GH animals (P = 0.1). Translocation to the general circulation expressed by the presence of organisms in systemic blood was detected in 0% of PN and 44% of GH rats (P < 0.05). Although exogenous GH improves gut mucosal structure in rats with SBS treated with PN, it seems to increase rather than decrease mucosal permeability to intestinal bacteria.

Bacterial translocation and T-lymphocyte populations in experimental short-bowel syndrome.

Bacterial translocation (BT) accounts in part for sepsis in short-bowel syndrome in which total parenteral nutrition (TPN) is routinely necessary. TPN "per se" facilitates BT and it has been suggested that decreased T-lymphocyte populations (TLP) in newborn rabbits and nude mice promote BT as well. We have tested the hypothesis that BT and modifications in TLP are to be expected in rats subjected to TPN and gut resection. Forty-five adult Wistar rats underwent central venous cannulations and were randomly assigned to one of three groups receiving for ten days three treatment regimes: - Group Sham (n = 17) oral intake of rat chow + saline (300 ml/kg/24 h) through a jugular vein catheter. - Group TPN (n = 17) fasting + infusion of all-in-one TPN solution (300 ml/kg/24 h). - Group RES (n = 11) fasting, same TPN regime + 80% gut resection. At the end of the experiment they were sacrified and specimens (peripheral and portal blood, spleen and mesenteric lymph nodes) were recovered, cultured and/or assessed for CD4+ and CD8+. Bacterial translocation was found in 47% of TPN animals, 92% of RES rats, but not in SHAM ones. Lymphocyte populations were not different in BT+ (n = 8) or BT- (n = 9) rats in the TPN group. TPN and resected animals showed a rise in CD4+ and a drop in CD8+ (then a better CD4+/CD8 ratio) when comparing with SHAM group rats. From this data we may conclude that: 1) BT is frequent if TPN is administered, and constant in resected animals. 2) No apparent relationship between the proportions of CD4+ and CD8+ lymphocytes and BT could be shown in TPN group. 3) High CD4+/CD8+ ratio in TPN and RES groups demonstrate that BT is possible even having good TLP.

Bloqueo auriculoventricular completo congénito familiar / Familial complete congenital atrioventricular block

Se estudia el bloqueo auriculoventricular completo congénito familiar. Se presentan dos hermanos que presentan esta afección. Se estudian los familiares de los niños hasta la segunda generación. El estudio no demostró enfermedades cardiovasculares asociadas, ni alteraciones electrocardiográficas. Los niños han permanecido asintomáticos hasta el momento actual(AU)