Docencia en grado y posgrado en Medicina de Urgencias y Emergencias en las facultades de medicina españolas / Undergraduate and post-graduate teaching of Emergency Medicine and Emergencies in Spanish medical schools

INTRODUCCIÓN: Analizar la situación actual y las características de la docencia en Medicina de Urgencias y Emergencias (MUE) en el grado y posgrado en las facultades de medicina españolas. MÉTODO: Análisis descriptivo de los planes de estudio de grado y posgrado de las 42 facultades de medicina españolas, identificando en los planes de estudio de sus páginas web las asignaturas con la denominación «Medicina de Urgencias-Emergencias» o «Medicina de Urgencias». RESULTADOS: De las 42 facultades de medicina, 38 (90,4%) presentan en sus planes de estudio asignaturas con denominación MUE. De las 38 facultades, 3 (2,4%) tienen MUE como materia obligatoria única no prácticas, 21 (50%) facultades tienen MUE como materia obligatoria no prácticas compartida con otras materias, 26 (61,9%) facultades tiene MUE como materia obligatoria en el rotario clínico o de práctica clínicas y 13 (31%) facultades tienen MUE como materia optativa. En 11 (26,2%) imparten un título de posgrado como máster o experto relacionado con la MUE. De las 11 facultades, 2 imparten dos o más títulos y las 9 restantes solo uno. Solo en 2 facultades el título del máster es oficial; las 9 restantes ofertan su formación con título propio. CONCLUSIONES: La enseñanza-aprendizaje de la MUE es incluida en los planes de estudio de las facultades de medicina españolas, de carácter obligatorio, optativo o de práctica clínica

INTRODUCTION: To analyse the situation and characteristics of medical education in Emergency Medicine (EM) in undergraduates and post-graduates in Spanish medical schools. METHODS: Data were collected and analysed from 42 Spanish schools of medicine. A search was conducted on each school of medicine's website curricula, identifying subjects under the name "emergency medicine" or "urgent medicine". RESULTS: Of the 42 schools of medicine, 38 (90.4%) present EM in their plans of study subjects. Of these 38 schools, 3 (2.4%) have EM as a single non-practical, compulsory subject, 21 (50%) schools have EM as a non-practical compulsory subject shared with other subjects, 26 (61.9%) schools have EM as a compulsory subject in the clinical practice, and 13 (31%) schools have EM as optional subject. Eleven schools (26.2%) had a postgraduate certificates related to emergency medicine, with two of them having 2 or more certificates, and 9 with only one. Only 2 had official certificates and the others were non-official certificates. CONCLUSIONS: This study clearly shows that teaching in emergency medicine is included in the undergraduate curricula in most Spanish medical schools as mandatory, optional, or in clinical rotation, however in postgraduate education, its implantation is low

Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial.

PURPOSE: To evaluate the efficacy of transpyloric feeding (TPF) compared with gastric feeding (GF) with regard to the incidence of ventilator-associated pneumonia in severe traumatic brain injury patients (TBI). DESIGN AND SETTING: Prospective, open-label, randomized study in an intensive care unit of a university hospital. PATIENTS: One hundred and four CHI adult patients admitted for TBI between April 2007 and December 2008. Patients were included within the first 24 h after ICU admission and were followed until discharge or 30 days after admission. INTERVENTION: Patients were randomized to TPF or GF groups. They received the same diet, with 25 kcal kg(-1) day(-1) of calculated energy requirements and a nitrogen intake of 0.2 g N kg(-1) day(-1). Primary outcome was the incidence of early and ventilatory-associated pneumonia. Secondary outcomes were enteral nutrition-related gastrointestinal complications (GIC), days on mechanical ventilation, length of ICU stay and hospital stay, and sequential organ failure assessment score (SOFA). RESULTS: The TPF group had a lower incidence of pneumonia, OR 0.3 (95% CI 0.1-0.7, P = 0.01). There were no significant differences in other nosocomial infections. The TPF group received higher amounts of diet compared to the GF group (92 vs. 84%, P < 0.01) and had lesser incidence of increased gastric residuals, OR 0.2 (95% CI 0.04-0.6, P = 0.003). CONCLUSIONS: Enteral nutrition delivered through the transpyloric route reduces the incidence of overall and late pneumonia and improves nutritional efficacy in severe TBI patients.

[Use of non-invasive ventilation in acute respiratory failure. Multicenter study in intensive care units]. / Utilización de la ventilación no invasiva en la insuficiencia respiratoria aguda. Estudio multicéntrico en unidades de cuidados intensivos.

OBJECTIVES: Study the use of non-invasive ventilation (NIV) in patients with acute respiratory failure in intensive care units (ICUs) in Spain. METHODS: A questionnaire was sent to 254 ICUs, after which, they were invited to participate in a multicenter, retrospective study, providing detailed information on ventilated patients. RESULTS: Answers were received from 123 hospitals. Of these, 119 used NIV, although its use varied greatly. NIV is the treatment of choice in 89% of the units for chronic obstructive pulmonary disease (COPD), in 79% for acute pulmonary edema (APE), in 53% for postextubation failure, in 53% for pneumonia 53%, and in 17% for acute respiratory distress syndrome (ARDS). It was used occasionally in COPD in 11% of the units, and in 21% of the units for APE. Eighteen hospitals provided additional information on 432 ventilated patients, 232 (54%) of whom received NIV as first line therapy. Presence of pneumonia or acute respiratory distress syndrome (ARDS) was an independent predictive factor of NIV failure (ORa=5.71; CI 95%, 1.83-17.8; p=0.003). Admission in a unit with experience in NIV in >50 patients/year (ORa=0.22; CI 95%, 0.07-0.63; p=0.005) and a higher PaO2/FiO2 ratio after one hour of ventilation (ORa=0.98 per point; CI 95%, 0.97-0.99; p<0.001) were protector factors. CONCLUSIONS: In Spain, NIV is widely used but it may continue to be underused in COPD and APE. The diagnosis of pneumonia or ARDS was an independent predictive risk factor. Admission in an ICU with NIV in more than 50 patients/year also have higher PaO2/FiO2 ratio after one hour of ventilation were predictive factors of success.

Efficiency of triiodothyronine treatment on organ donor hemodynamic management and adenine nucleotide concentration.

OBJECTIVE: We compared hemodynamic values, oxygen utilization, and adenine nucleotide concentration in the extracted organs of brain-dead donors treated with triiodothyronine vs. standard support treatment. DESIGN: Prospective, randomized, double-blind controlled study. PATIENTS: We recruited 52 consecutive adult cadaveric organ donors. Inclusion criteria were diagnosis of brain-death, transplantation suitability, and family consent for donation; exclusion criterion was preexisting thyroid disease. INTERVENTIONS: The treatment group (n=29) received an intravenous bolus of 1 microg/kg triiodothyronine followed by continuous perfusion at 0.06 microg/kg per hour, and controls (n=23) received 0.9% ClNa delivered over 270 min. Hemodynamics, tonometry, thyroid hormones, and serum lactate were measured every 90 min from brain death to extraction procedure. Biopsies were processed to determine adenine nucleotides concentration. RESULTS: Hemodynamic measurements did not differ significantly in the two groups, and the inotrope dose could not be diminished after treatment. Thyrotropin levels increased from brain death to extraction procedure in controls. Thyrotropin measured 90 and 180 min after the beginning of the perfusion was significantly lower in the treatment group than controls. The Pco2 gap increased in both groups from brain death to the extraction procedure. The lactate level of the treatment group was lower than in controls. Biopsy specimens were obtained in 19 controls and in 20 donors of the treatment group; the adenine nucleotides concentration did not show any significant difference. CONCLUSIONS: Triiodothyronine did not add any benefit over the standard management of the organ donor nor did it affect the adenine nucleotides concentration of any biopsied organs.

Noninvasive pressure support versus proportional assist ventilation in acute respiratory failure.

BACKGROUND: Although conventional pressure ventilation (PSV) decreases the rate of intubation in acute respiratory failure, patient-ventilator dyssynchrony is a frequent cause of failure. In proportional assist ventilation (PAV), pressure is applied by the ventilator in proportion to the patient-generated volume and flow; therefore, there is automatic synchrony between the patient's effort and the ventilatory cycle. OBJECTIVE: The aim of this study was to compare the effects of PSV and PAV during noninvasive ventilation in the treatment of acute respiratory failure. DESIGN: Prospective randomised study. SETTING: A multidisciplinary 24-bed intensive care unit of an acute-care teaching hospital in Alicante, Spain. PATIENTS. This study included 117 consecutive adult patients with acute respiratory failure randomised to noninvasive ventilation delivered by PSV ( n = 59) or PAV ( n = 58). MEASUREMENTS AND RESULTS: There were no statistically significant differences between patients assigned to each mode of ventilation with regard to baseline parameters and aetiological diagnoses of acute respiratory failure. With regard to outcome data, no significant differences were observed between PSV and PAV in the frequency of intubation (37% vs 34%), mortality rate (29% vs 28%), and mean length of stay. Subjective comfort (0-10 visual analogue scale) was rated higher and intolerance occurred less frequently (3.4% vs 15%, P = 0.03) in the PAV than in the PSV mode. CONCLUSIONS: Although PAV seems more comfortable and intolerance occurred less frequently, no major differences exist in terms of physiological improvement or in terms of outcomes when comparing PSV and PAV.