[Impact of noninvasive ventilation failure upon patient prognosis. Subanalysis of a multicenter study]. / Impacto del fracaso de la ventilacion no invasiva en el pronóstico de los pacientes. Subanálisis de un estudio multicéntrico.

OBJECTIVE: Noninvasive ventilation (NIV) constitutes first-line treatment for the exacerbation of obstructive pulmonary disease and cardiogenic lung edema. Several studies suggest that NIV failure could increase the risk of mortality, mainly due to the delay in tracheal intubation. We aimed to evaluate the negative impact of NIV failure in routine practice among Spanish ICUs. PATIENTS: A subanalysis was made of the multicenter validation of the Sabadell Score study, extracting patients with acute respiratory failure requiring either invasive or noninvasive mechanical ventilation, with the exclusion of patients presenting "do not resuscitate and/or do not intubate" orders. VARIABLES: We recorded demographic parameters, ICU-specific treatments and the development of acute renal failure or infections during ICU stay. Patients were followed-up on until hospital discharge or death. The statistic analysis included Cox multiple logistic regression. RESULTS: We analyzed 4132 patients, of whom 1602 (39%) received only invasive mechanical ventilation (IMV), while 529 (13%) received NIV. The latter succeeded in 50% of the patients, but the other 50% required intubation. NIV failure was more common in neurological and postsurgical patients. Mortality was lower than predicted in NIV patients (22% vs. 33%) and similar to predicted in IMV patients (27% vs. 29%). Mortality was lower than predicted in patients in whom NIV proved successful (12% vs. 28%), and in those in whom NIV failed (32% vs. 38%). CONCLUSION: NIV failure and the need of intubation as routinely used do not seem to imply a poorer patient prognosis.

[Nutrition and anaemias in critical illness]. / Nutrición y anemias en pacientes graves.

INTRODUCTION: We made a clinical study, about nutrition in seriously ill patients, which includes a typical heterogeneous group of critical ill patients, with/without anaemia's, that have been admitted to Intensive Care Unit, ICU. It is difficult to individualize and to generalize the relative importance of all the factors that can contribute to these anaemia's in the admission to the Unit, including nutritional deficiencies, inflammatory alterations, the immune response to aggressions, inmunitary modifications and the complex relations existing between these clinic processes. OBJECTIVE: Indirect valuation of the nutritional situation and anaemia's, in a typical heterogeneous group of critical ill patients. METHOD/RESULTS: We studied 202 patients admitted to ICU, of varied and heterogeneous origin, classifying them in 3 groups: control, post surgery and septic group's, becoming the indirect valuation of the nutritional situation on the basis of: Global Subjective Valuation, (VGS) and the nutritional analytical determinations of total lymphocytes, albumin, and transferrin. Also we made hemogram and determinations of sideremia and ferritinemia to all of them. In 57% of the patients, we observed levels haemoglobin < 12.5 g/dl, basically in the post surgery groups, 68 patients and septic group's, 10 patients. And with levels haemoglobin < 10 g/dl, in 25 patient's (12.3%). There were 87 patients, 23 of them in the control group's, 58 in the post surgery and 5 septic group's, with levels haemoglobin > 12.5 g/dl. Regarding the nutritional prognoses indicators, (VGS + nutritional profile), in the control group's, they did not present anaemia nor analytical clinical under nourishment, in the post surgery group's, anaemia and slight under nourishment and in the septic group's, anaemia and moderate under nourishment. There were significant differences between the surgery and septic group and control group's, in values of haemoglobin, iron, total lymphocytes, transferrin and albumin. A statistical correlation between sideremia and albumin was significative. (Spearman's Rho 0,277). CONCLUSIONS: The evaluation of the anaemia and nutritional valuation. and the ferroterapic treatment, as immune-nutrient, can be beneficial for the integrity of the immune system and its defense's abilities against the aggressions in critically ills.

Nutrición y anemias en pacientes graves / Nutrition and anaemias in critical illness

Introducción: Realizamos un estudio clínico original sobre nutrición en pacientes graves, que incluye a un grupo heterogéneo típico de pacientes críticos, con/sin anemias, que nos han ingresado en la Unidad de Cuidados Intensivos, UCI. Es difícil individualizar y generalizar la relativa importancia de todos los factores que pueden contribuir a estas anemias en la admisión en la Unidad, incluyendo las deficiencias nutricionales, las alteraciones inflamatorias, la respuesta a las agresiones, las modificaciones inmunitarias y las complejas relaciones existente entre estos procesos clínicos. Objetivo: Valoración indirecta de la situación nutricional y anemias, en un grupo heterogéneo típico de pacientes críticos. Método/Resultados: Se estudian 202 pacientes ingresados en la UCI, de variada y heterogénea procedencia, y clasificándolos en 3 grupos: control, postoperados y sépticos, realizándose la valoración indirecta de la situación nutricional en base a: la Valoración Global Subjetiva, (VGS), y las determinaciones analíticas nutricionales pronosticas de linfocitos totales, albúmina, y transferrina. También se realizo hemograma y determinaciones de sideremia y ferritinemia a todos ellos. En un 57% de los pacientes, se observo cifras de hemoglobina inferior a 12.5 gr/dl, básicamente en el grupo de postoperados, (68 pacientes) y sépticos, (10 pacientes). Y con cifras inferiores a 10 g/dl de hemoglobina, en 25 pacientes mas, (12,3%). Hubo 87 pacientes, 23 de ellos en el grupo control, 58 en los postoperados y 5 sépticos, cuya cifra de hemoglobina era superior a 12,5 g/dl. En cuanto a los indicadores pronósticos nutricionales, (VGS + perfil nutricional), en el grupo control no presentaban anemia ni desnutrición clínico analítica, en los postoperados, anemia y desnutrición leve y en los sépticos, anemia y desnutrición ligera-moderada. Había diferencias significativas entre los pacientes del grupo control y los grupos postoperados y sépticos, en cuanto a la cifra de hemoglobina, hierro, linfocitos totales, transferrina y albúmina. Se hizo una correlación estadística entre la sideremia y la albúmina, existiendo significación estadística. (Coef Rho de Spearman 0,277). Conclusión: La valoración de la anemia y de la situación nutricional y el tratamiento ferroterapico, como inmunonutriente, pudiera ser beneficioso para la integridad del sistema inmune y su capacidad de defensa ante las agresiones, en pacientes graves ingresados en la UCI (AU)

Introduction: We made a clinical study, about nutrition in seriously ill patients, which includes a typical heterogeneous group of critical ill patients, with/without anaemia's, that have been admitted to Intensive Care Unit, ICU. It is difficult to individualize and to generalize the relative importance of all the factors that can contribute to these anaemia's in the admission to the Unit, including nutritional deficiencies, inflammatory alterations, the immune response to aggressions, inmunitary modifications and the complex relations existing between these clinic processes. Objective: Indirect valuation of the nutritional situation and anaemia's, in a typical heterogeneous group of critical ill patients. Method/Results: We studied 202 patients admitted to ICU, of varied and heterogeneous origin, classifying them in 3 groups: control, post surgery and septic group's, becoming the indirect valuation of the nutritional situation on the basis of: Global Subjective Valuation, (VGS) and the nutritional analytical determinations of total lymphocytes, albumin, and transferrin. Also we made hemogram and determinations of sideremia and ferritinemia to all of them. In 57% of the patients, we observed levels haemoglobin < 12.5 g/dl, basically in the post surgery groups, 68 patients and septic group's, 10 patients. And with levels haemoglobin < 10 g/dl, in 25 patient's (12.3%). There were 87 patients, 23 of them in the control group's, 58 in the post surgery and 5 septic group's, with levels haemoglobin > 12.5 g/dl. Regarding the nutritional prognoses indicators, (VGS + nutritional profile), in the control group's, they did not present anaemia nor analytical clinical under nourishment, in the post surgery group's, anaemia and slight under nourishment and in the septic group's, anaemia and moderate under nourishment. There were significant differences between the surgery and septic group and control group's, in values of haemoglobin, iron, total lymphocytes, transferrin and albumin. A statistical correlation between sideremia and albumin was significative. (Spearman's Rho 0,277). Conclusions: The evaluation of the anaemia and nutritional valuation. and the ferroterapic treatment, as immune-nutrient, can be beneficial for the integrity of the immune system and its defense's abilities against the aggressions in critically ills (AU)

Factores relacionados con el desarrollo de preeclampsia. Revisión de la bibliografía / Factors related to the development of preeclampsia. A literature review

No disponible

Seguridad del paciente. Una necesidad para el cuidado / Patient safety, a the need of care

Reducir los eventos adversos y errores médicos se ha convertido en un asunto de interés Internacional, por tal motivo en octubre del 2004 la Organización Mundial de la Salud (OMS) estableció la alianza por la seguridad del paciente, realizando un primer taller en el cual se establecieron seis áreas de acción, una de ellas; los pacientes en defensa de su seguridad realizada en noviembre del 2005 en Londres, con 24 asistentes mujeres de Sudan, Australia y México se presento la llamada Declaración de Londres en donde se destaca la perspectiva de los pacientes como agentes de cambio activos en la mejora de la calidad de los servicios de salud, en especial los derechos a la salud materno infantil, exponiendo sus propias historias de vida uno de los puntos principales y de mayor relevancia fue el de enfocar la atención a los grupos mas desprotegidos y discriminados por lo que se propuso crear redes con las Instituciones, grupos y Asociaciones civiles con EE. UU, Canadá para trabajar a nivel regional y mundial en forma conjunta con la OMS.

Decreasing adverse events and medical errors has become an international health issue, therefore in October 2004 the WHO (World Health Organization) established the Alliance for Patient Safety by performing one first workshop in which 6 action areas were set; 1. the campaign for nosocomial infections prevention, 2. Patient safety investigation, 3. Patient safety taxonomy, 4. Reporting and Learning for Patient Safety, 5. Solutions for Reducing Risks, and the 6th " Patients for the Defense of their Safety" that was developed through families and was pushed out by people who suffered damage by medical errors and that have worked to improve health services quality. With this in mind in November 2005 in London with 24 female attendants from Sudan, Australia, and Mexico, the so called London Statement was presented, where the perspective of patient as an active change agent for improving health service quality was highlighted, specially the rights for mother-child health, by means of exposing their own life stories. One of the main issues and with mayor relevance was to focus attention on assistance for the less protected and discriminated groups, and it was proposed to create networks bonds with those institutions, associations, and groups, and civil associations that work at regional and world levels such as those in the USA and Canada, and that work jointly with the WHO.

[MARS (Molecular Absorbent Recirculating System) as hepatic extracorporeal care in serious acute liver failure of alcoholic etiology]. / MARS (molecular adsorbent recirculating system) como asistencia extracorporea hepatica en el fracaso hepatica en el fracaso hepatico agudo grave de etiologia enolica.

Acute liver failure with criteria of seriousness and alcoholic etiology is a picture of worldwide distribution, with an elevated mortality, of approximately 50%, that requires admission to the ICU. Acute serious alcoholic hepatitis is defined by a Maddrey score value > 32 and/or spontaneous encephalopathy. Together with the classical treatment with corticosteroids and nutritional supplements, alcoholic abstinence and others such as anti-TNF therapy, we introduce MARS (Molecular Adsorbent recirculating System) as a extracorporeal liver assistance system with detoxification function, that is presented as a support measure that makes it possible to maintain the patient in good conditions until an organ becomes available or until the functional recovery of the native liver. In our case, MARS has shown some spectacular results and above all, results maintained over time, associated to the rest of the therapeutic measures characteristic of this disease.

MARS (molecular adsorbent recirculating system) como asistencia extracorpórea hepática en el fracaso hepático agudo grave de etiología enólica / MARS (molecular absorbent recirculatingsystem) as hepatic extracorporeal carein serious acute liver failure of alcoholicetiology

La insuficiencia hepática aguda con criterios de gravedad y etiología enólica es un cuadro de amplia distribución mundial, con una elevada mortalidad, aproximadamente el 50%, y requiere ingreso en la Unidad de Cuidados Intensivos (UCI). La hepatitis alcohólica aguda grave está definida por un valor de Maddrey score > 32 y/o encefalopatía espontánea. Junto al tratamiento clásico con corticoides y suplementos nutricionales, abstinencia alcohólica y otros, como las terapias anti-factor de necrosis tumoral (anti-TNF) introducimos el MARS (molecular adsorbent recirculating system) como sistema de asistencia extracorpórea hepática con función de detoxificación, que se presenta como una medida de soporte que permite mantener al paciente en buenas condiciones hasta la disponibilidad de un órgano o hasta la recuperación funcional del hígado nativo. En nuestro caso, el MARS ha mostrado unos resultados espectaculares y, sobre todo, mantenidos en el tiempo, asociado al resto de las medidas terapéuticas propias a esta patología

Acute liver failure with criteria of seriousness and alcoholic etiology is a picture of worldwide distribution, with an elevated mortality, of approximately 50%, that requires admission to the ICU. Acute serious alcoholic hepatitis is defined by a Maddrey score value > 32 and/or spontaneous encephalopathy. Together with the classical treatment with corticosteroids and nutritional supplements, alcoholic abstinence and others such as anti-TNF therapy, we introduce MARS (Molecular Adsorbent recirculating System) as a extracorporeal liver assistance system with detoxification function, that is presented as a support measure that makes it possible to maintain the patient in good conditions until an organ becomes available or until the functional recovery of the native liver. In our case, MARS has shown some spectacular results and above all, results maintained over time, associated to the rest of the therapeutic measures characteristic of this disease

Hemorragia alveolar difusa en una gestante / Diffuse alveolar hemorrhage in pregnancy

La hemorragia alveolar difusa es una complicación muy grave debida generalmente a una vasculitis capilar pulmonar dentro de una enfermedad autoinmune. Tiene una incidencia muy baja, y en los casos de lupus eritematoso sistémico es menor del 2%. No hay datos fiables en gestantes por ser una complicación poco frecuente, pero conlleva una mortalidad muy elevada. El tratamiento consiste en inmunosupresión y plasmaféresis para eliminar los anticuerpos patogénicos, además del soporte vital necesario. Otras medidas de tipo profiláctico, como aspirina o prednisona, para evitar la pérdida fetal durante el embarazo no están del todo probadas. La utilización de otro tipo de medicación para prevenir o minimizar complicaciones, como el factor VII recombinante activado (FrVIIa), para controlar la hemorragia, es un hecho novedoso en este tipo de pacientes. Presentamos el caso de una gestante con enfermedad autoinmune, ingresada en la unidad de cuidados intensivos por una gestosis grave, que presentó un cuadro de hemorragia alveolar difusa tras la cesárea, que inicialmente se controló con FrVIIa

Diffuse alveolar hemorrhage is a very serious complication usually due to a pulmonary capillary autoimmune vasculitis. Its incidence is very low and in cases of systemic lupus erythematosus is less than 2%. Because of its low frequency, there are no reliable data in pregnant women but mortality is high. Treatment consists of immunosuppression and plasmapheresis to eliminate the pathogenic antibodies and providing the required life support measures. The usefulness of prophylactic management with aspirin or prednisone to avoid intrauterine fetal death has not been demonstrated. The utilization of another type of drug to prevent or control bleeding complications, such as activated recombinant factor VII (rFVIIa), is promising in this type of patient. We present the case of a pregnant woman with autoimmune disease, who was admitted to the intensive care unit due to severe gestosis, and who suffered an episode of diffuse alveolar hemorrhage after caesarean section. The hemorrhage was initially controlled with rFVIIa

[Creatine kinase increases after coronary interventions]. / Elevaciones de la creatincinasa tras intervencionismo coronario.

INTRODUCTION AND OBJECTIVES: Percutaneous revascularization has led to an important change in the treatment of patients with symptomatic ischemic heart disease in recent years. There is controversy concerning the incidence and prognostic significance of postprocedural increases in creatine kinase. The aim of this study was to assess the incidence of these elevations and the related factors and to observe the prognosis of patients with and without creatin kinase elevations. METHODS: We reviewed 447 patients in whom an angioplasty was done in our department from January 1997 to June 1998, excluding 138 patients with myocardial infarction in the previous four days or unsuccessful angioplasty. Creatine kinase was measured in all patients at 0, 4, 8 and 24 hours after angioplasty. We analyzed the incidence of elevated levels of creatine kinase following coronary surgery and the characteristics of the patients in comparison with a control group made up of patients who, at a similar time had undergone a similar angioplasty procedure including, a similar vessel and type of lesion, and equivalent left ventricular function but without elevated serum levels of creatine kinase. Major adverse coronary events were defined as: cardiac death, nonfatal myocardial infarction, new revascularization and unstable angina in which hospitalization was required. RESULTS: Out of 309 patients studied, an elevation in creatine kinase was observed in 24 patients (7.7%). Complications related to the procedure were found in 50% of these elevations, most of which involved side branch occlusion. There were no differences with respect to the demographical or anatomical characteristics of the lesions in the groups studied. During the follow-up of 9.5 months, complications were observed in 37.5% of the group of patients with elevated creatine kinase levels and in 20% of the control group, but this difference did not achieve statistical significance. CONCLUSIONS: Creatine kinase elevations are produced in 7.7% of the patients after coronary angioplasty. Complications related to the procedure were observed in 50% of the cases, most being side branch occlusion and no complications were seen in the remaining patients. Continuous measurement of creatine kinase after angioplasty shows a low sensitivity for detecting complications during follow-up. New, more sensitive and specific cardiac markers, such as troponin, could define this group of patients.

[Perspectives of chronically ill patients concerning medical care in Guadalajara, Mexico: a qualitative study]. / La perspectiva de enfermos crónicos sobre la atención médica en Guadalajara, México. Un estudio cualitativo.

This paper reports partial findings from a broader study on the experience of people with chronic diseases. The objective was to explore the perspectives of diabetic patients towards medical care. A qualitative study was conducted in a poor neighborhood of Guadalajara, Mexico. Thirty subjects with diabetes mellitus participated in the study. Data was gathered by open and semi-open interviews in the subjects' homes and over the course of one year. Data were analyzed using a combination of content and conversational analyzing techniques. Three perspectives predominated when participants evaluated medical care: some define it as good, some as ambivalent, and the rest as bad. These perspectives were closely linked to their disease experience and available medical options according to their material resources. These perspectives change with time, are specific to each available service and type of medical care, and are constructed in terms of all the subjects' present chronic illnesses. Those treated through the social security system evaluate the care in negative terms, with the opposite occurring with those treated in public health care centers and private facilities. Implications regarding health care reform are discussed.

Alpha 1-antitrypsin deficiency caused by the alpha 1-antitrypsin Nullmattawa gene. An insertion mutation rendering the alpha 1-antitrypsin gene incapable of producing alpha 1-antitrypsin.

alpha 1-Antitrypsin (alpha 1AT) deficiency is a hereditary disorder associated with reduced serum alpha 1AT levels and the development of pulmonary emphysema. An alpha 1AT gene is defined as "Null" when no alpha 1AT in serum is attributed to that alpha 1AT gene. Although all alpha 1AT Null genes have identical phenotypic consequences (i.e. no detectable alpha 1AT in the serum), different genotypic mechanisms can cause the Null state. This study defines the molecular basis for the alpha 1AT gene Nullmattawa, identified and cloned from genomic DNA of an individual with the Null-Null phenotype and emphysema resulting from the heterozygous inheritance of the Nullmattawa and Nullbellingham genes. Sequencing of exons Ic-V and all exon-intron junctions of the Nullmattawa gene demonstrated it was identical to the common normal M1(Val213) alpha 1AT gene except for the insertion of a single nucleotide within the coding region of exon V, causing a 3' frameshift with generation of a premature stop signal. Family analysis using oligonucleotide probes specific for the Nullmattawa sequence demonstrated the gene was inherited in an autosomal fashion. Examination of blood monocytes demonstrated that a normal-sized, 1.8-kb alpha 1AT mRNA transcript is associated with the Nullmattawa gene and in vitro translation of mRNA with the Nullmattawa mutation showed it translated at a normal rate but produced a truncated alpha 1AT protein. Additionally, retroviral transfer of the alpha 1AT Nullmattawa cDNA to murine fibroblasts demonstrated no detectable intracellular or secreted alpha 1AT, despite the presence of alpha 1AT Nullmattawa mRNA transcripts. These findings are consistent with the concept that the molecular pathophysiology of Nullmattawa is likely manifested at a posttranslational level. The identification of the Nullmattawa gene supports the concept that Null alpha 1AT alleles represent a heterogenous group in which very different mechanisms cause the identical phenotypic state.