[Evaluation of the management of inhalers by the nursing personnel in a reference hospital]. / Valoración del manejo de los inhaladores por el personal de enfermería en un hospital de referencia.

OBJECTIVES: To evaluate the knowledge and skills of nurses on the management of inhaled therapy in different hospitalization wards. MATERIAL AND METHODS: We carried out a cross-sectional study, in which nurses were asked to perform a practical demonstration of the management of a pressurized canister with an inhalation chamber, without previous theoretical instruction about the technique. The inhalation technique was evaluated step by step following the recommendations of the Spanish Society of Pneumologists and Chest Surgeons (SEPAR). RESULTS: We could obtain the participation of 144 of the 177 nurses working in different wards (29 males, 115 females, mean age 42.5 + 7 years). Previous knowledge of the management of inhalers was declared by 85.4%. We found that 70.8% of the nurses did not correctly perform all the steps: 24.5% made only one mistake, while the rest had mistakes in two or more steps. The most common mistakes were: not to perform a slow and deep exhalation before using the inhaler (27.3%), not to hold the breath after the inhalation (24.4%), and not to wait 30 seconds between inhalation manoeuvres (21.5%). When evaluating different wards, we found that 44.4% of the nurses in the Short Stay Unit performed the technique correctly in contrast to 31.3% of the nurses in the Pneumology Ward. CONCLUSIONS: The percentage of mistakes in the inhalation technique by the nursing personnel was high. The health personnel must have an adequate level of training in order to correctly instruct the patient, because the efficacy of inhaled treatment greatly depends on the adequacy of the technique.

Valoración del manejo de los inhaladores por el personal de enfermería en un hospital de referencia / Evaluation of the managemente of inhalers by the nursing personner in a reference hospital

Objetivo: valorar los conocimientos y adiestramiento del personal de enfermería con el paciente respiratorio en el manejo de la terapia inhalada en distintas salas de hospitalización.Material y métodos: se diseñó un estudio prospectivo con 144 enfermos/as mediante una encuesta individual en la que se solicitó a cada unode ellos una demostración práctica del manejo del cartucho presurizado con cámara inhalatoria, sin realizar una instrucción teórica previa sobrela técnica. Se revisó la técnica inhalatoria siguiendo los pasos establecidos en la normativa SEPAR.Resultados: participaron 144 de los 177 enfermeros/as (81,4%) que trabajan en las diferentes salas de hospitalización (29 varones, 115 mujeres,edad media 42,5 + 7 años). El 85,4% (123/144) reconocía tener conocimientos previos del manejo de los inhaladores. Tras la demostración práctica se comprobó que el 70,8% de los enfermeros realizaban incorrectamente algún paso de la maniobra inhalatoria; de ellos el 24,5% cometió un sólo error y el resto dos o más. Los errores más frecuentes fueron: no efectuar una espiración lenta y profunda antes de iniciar la inhalación (27,3%), no aguantar la respiración durante 10 segundos (24,4%), y no esperar 30 segundos antes de iniciar la siguiente inhalación (21,5%). Analizando estos resultados por salas de hospitalización, el 44,4% de la Unidad de Corta Estancia efectuaba correctamente la técnica frente al 31,3% en Neumología. Conclusiones: el porcentaje de errores en la técnica de inhalación es elevado por parte del personal de enfermería. Es importante que el personal sanitario posea un grado de conocimientos adecuado para poder instruir adecuadamente al paciente, ya que de ello depende en gran medida la eficacia del tratamiento

Objectives: To evaluate the knowledge and skills of nurses on the management of inhaled therapy in different hospitalization wards. Material and methods: We carried out a cross-sectional study, in which nurses were asked to perform a practical demonstration of the management of a pressurized canister with an inhalation chamber, without previous theoretical instruction about the technique. The inhalation technique was evaluated step by step following the recommendations of the Spanish Society of Pneumologists and Chest Surgeons (SEPAR). Results: We could obtain the participation of 144 of the 177 nurses working in different wards (29 males, 115 females, mean age 42.5 + 7 years). Previous knowledge of the management of inhalers was declared by 85.4%. We found that 70.8% of the nurses did not correctly perform all the steps: 24.5% made only one mistake, while the rest had mistakes in two or more steps. The most common mistakes were: not to perform a slow and deep exhalation before using the inhaler (27.3%), not to hold the breath after the inhalation (24.4%), and not to wait 30 seconds between inhalation manoeuvres (21.5%). When evaluating different wards, we found that 44.4% of the nurses in the Short Stay Unit performed the technique correctly in contrast to 31.3% of the nurses in the Pneumology Ward. Conclusions: The percentage of mistakes in the inhalation technique by the nursing personnel was high. The health personnel must have an adequate level of training in order to correctly instruct the patient, because the efficacy of inhaled treatment greatly depends on the adequacy of the technique

Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission.

OBJECTIVE: To evaluate adherence to guidelines when choosing an empirical treatment and its impact upon the prognosis of community-acquired pneumonia (CAP). METHODS: A prospective multicentre study was conducted in 425 CAP patients hospitalized on ward. Initial empirical treatment was classified as adhering or not to Spanish guidelines. Adherent treatment was defined as an initial antimicrobial regimen consisting of beta-lactams plus macrolides, beta-lactam monotherapy and quinolones. Non-adherent treatments included macrolide monotherapy and other regimens. Initial severity was graded according to pneumonia severity index (PSI). The end point variables were mortality, length of stay (LOS) and re-admission at 30 days. RESULTS: Overall 30-day mortality was 8.2%, the mean LOS was 8+/-5 days, and the global re-admission rate was 7.6%. Adherence to guidelines was 76.5%, and in most cases the empirical treatment consisted of beta-lactam and macrolide in combination (57.4%). Logistic regression analysis showed that other regimens were associated with higher mortality OR=3 (1.2-7.3), after adjusting for PSI and admitting hospital. Beta-lactam monotherapy was an independent risk factor for re-admission. LOS was independently associated with admitting hospital and not with antibiotics. CONCLUSIONS: A high adherence to CAP treatment guidelines was found, though with considerable variability in the empirical antibiotic treatment among hospitals. Non-adherent other regimens were associated with greater mortality. Beta-lactam monotherapy was associated with an increased re-admission rate.

[Characteristics of tuberculosis in a tertiary hospital during the years 1993-1996. Influence of the coinfection with HIV]. / Características de la tuberculosis en un hospital terciario durante los años 1993-1996. Influencia de la coinfección por el VIH.

To assess and compare epidemiological factors, clinical and radiological signs, laboratory results and drug resistance in patients with tuberculosis (TB) with and without AIDS. Retrospective study of TB diagnosed bacteriologically between January 1993 and December 1996 at Hospital Universitario La Fe. Annual rates were 41.7, 47.1, 34.6 and 43.8 per 100,000 inhabitants in 1993 to 1996, respectively. AIDS was present in 22.4%. TB was pulmonary in 87% and 49.4% in patients without and with AIDS, respectively. Incidence was higher in the 25 to 34 age range. Prior contact with TB patients was established in 19.2% of cases. Pulmonary TB in patients with AIDS presented with normal lung X-rays in 30.1%; 16.2% of these had positive sputum cultures. Pulmonary cavitation was evident in 32.6% of TB patients without AIDS and 6.8% of those with AIDS. Pulmonary TB was diagnosed by culture of sputum taken at the time of admission in 25.9% of non AIDS patients and in 12.4% of patients with AIDS. Extrapulmonary TB was diagnosed by culture in most cases. Such forms predominated among TB plus AIDS patients, with most cases being ganglial and urogenital. Overall drug resistance was 8.3% (7.4% non-AIDS/11.5% AIDS). Primary resistance (PR) was 6.3% and 7.1%, PR to hydrazides was 5% and 5.4%, and secondary resistance was 32.4% and 33.3%. Drug resistance in non-AIDS and AIDS patients, was associated with a history of TB and past treatment (p < 0.009), prior contact with TB patients (p < 0.004) and pulmonary cavitatin (p < 0.02). TB with AIDS tends to occur in a younger population, is often extrapulmonary or with atypical lung involvement. Drug resistance is similar in patients with and without AIDS.

[Infection by Strongyloides stercoralis in the county of Safor, Spain]. / Infección por Strongyloides stercoralis en la comarca de La Safor (Comunidad Valenciana).

BACKGROUND: Strongyloides stercoralis is an endemic nematode in tropical and subtropical regions, but almost unknown in Spain. PATIENTS AND METHODS: In order to know some epidemiological, clinical and analytic features of this infection in our area (La Safor, Valencia), we performed a prospective study for 19 months. Through the search for the parasite in feces of patients with eosinophilia, we identified 37 subjects who were studied at diagnosis and 4 months later. RESULTS: Thirty-three patients (89%) were currently, or had been agricultural workers, and thirty had worked barefooted and/or had drunk contaminated irrigation water. Twenty-three patients (62%) had a chronic or immunosuppressive diseases, and two of them on steroid treatment, developed a disseminated strongyloidiasis. Thirteen patients (35%) were asymptomatic; the rest had clinical manifestations attributed S. stercoralis, mainly digestive. Two of the patients with disseminated strongyloidiasis also had concomitant bacterial infections by Streptococcus bovis, Streptococcus faecalis and Enterobacter sp. At diagnosis, besides eosinophilia, 86.5% had raised levels of IgE. Four months later treatment, the number of eosinophils was normal and IgE levels significantly decreased. The diagnostic yield of parasitic study of feces was increased with the number of samples examined. Thiabendazole achieved erradication of the parasite in 35 patients, and the other two died because of disseminated strongyloidiasis. CONCLUSIONS: The presence of eosinophilia in patients from rural areas with subtropical climate should raise suspicion about infection by S. stercoralis, which, although sometimes is asymptomatic, may cause systemic bacterial infections in cases of hyperinfestation, specially when glucocorticoid treatment is given.

[The prognostic factors for early mortality and for total or partial gammagraphic resolution in venous thromboembolic disease]. / Factores pronósticos de la mortalidad precoz y de la resolución total o parcial gammagráfica en la enfermedad tromboembólica venosa.

Our objective was to investigate possible factors implicated in either early death from or scintigraphic resolution of pulmonary embolism. To that end we conducted a retrospective study of 116 patients with either a high likelihood of pulmonary thromboembolism (PTE) diagnosed by scintiscan or with a fair probability of PTE by scintiscan accompanied by a positive phlebograph. The images were taken upon admission, at 7 days, 10 days and 6 months. The factors analyzed were age, sex, trauma, immobility, surgery, obesity, hemiplegia, venous insufficiency, cardiopulmonary disease, neoplasia, chest X-ray and ECG alterations, D(A-a)O2 and size of perfusion defects upon admission and 7 to 10 days later. We performed single-variable analyses and multiple logical regression analyses using perfusion defect at 6 months as the dependent variable. The early mortality rate (13%) was higher in patients with neoplasms, a larger alveolar-arterial index and greater perfusion defects upon admission. Scintiscans became normal in 28%. Multivariate analysis to predict total or partial resolution at 6 months showed that size of perfusion defects at 7 to 10 days was the best predictive factor. A cutoff point was calculated by analyzing the ROC for this factor. Thus, when the defect at 7 to 10 days was equal to or greater than 1 segment, the probability of residual defects remaining after 6 months was twice as great (sensitivity 83%, specificity 57%). In conclusion, early death was more likely in PTE patients with neoplasms, larger defects upon admission and greater alveolar-arterial difference. Scintigrams showed resolution 6 months after admission in 28%. The size of perfusion defects 7 to 10 days after admission was the factor that best predicted total of partial resolution at 6 months.

[Strongyloides stercoralis infection in patients with bronchial obstructive pathology]. / Infección por Strongyloides stercoralis en pacientes con patología bronquial obstructiva.

Strongyloides stercoralis infection was hardly seen in Spain until a few years ago but has recently been shown to be fairly common in some geographic areas. In the respiratory tract this germ can cause acute bronchospasms that make diagnosis difficult, particularly in patients with underlying bronchial disease. To determine if curing S. stercoralis infection is accompanied by clinical and functional improvement in patients with bronchial obstruction, we studied the evolution of 22 infected patients: 11 with no bronchopulmonary disease and 11 with chronic airway obstruction or asthma. The following variables were assessed in both groups at the moment of diagnosis of infection and four months after cure: levels of eosinophils and total serum IgE, respiratory symptoms, steroid doses and spirometric parameters. After four months we observed a significant decrease in eosinophil (16 versus 5%) and IgE (1,600 versus 770 IU/ml) levels in both groups. The number of bronchospasms and daily steroid doses required decreased in the group with bronchial disease. No significant differences were seen in spirometric parameters, however. The improvement in respiratory symptoms, blood parameters and need for medication leads us to believe that airway inflammation decreases after the infection has been eradicated, in spite of the lack of improvement in bronchial obstruction.

[Strongyloides stercoralis infection in a cortico-dependent patient with chronic airflow obstruction]. / Infección por Strongyloides stercoralis en un paciente con obstruccion crónica al flujo aéreo corticodependiente.

We report a case of Strongyloides stercoralis infection in a male agricultural worker with corticoid dependent chronic obstructive air flow disease and bronchial hyperreactivity. The clinical picture initially involved digestive symptoms and bronchospasm resistant to steroid treatment. Diagnosis was established by demonstrating the larvae of S. stercoralis in stool. We emphasize that this infection should be suspected in patients living in endemic areas such as Spain, and describe S. stercoralis-caused respiratory manifestations that can be masked by bronchial disease.

[Large-cell lung carcinoma producing chorionic gonadotropin hormone: the difficulty in its differential diagnosis from choriocarcinoma]. / Carcinoma pulmonar de células grandes productor de hormona gonadotrofina coriónica: dificultad en el diagnóstico diferencial con un coriocarcinoma.

We describe a patient with giant cell carcinoma with ectopic production of chorionic gonadotrophin hormone (CGH). This entity is compared with choriocarcinoma, given that the immunologic, histologic and chemical similarities between the two neoplasms can make their anatomic and pathologic differential diagnosis difficult. Clinical examination, response to treatment and CGH blood levels are the criteria for differentiation.