Encuesta nacional sobre los indicadores de calidad en Bioética de la SEMICYUC, en los servicios de Medicina Intensiva en España / National survey on the indicators of quality in Bioethics of the SEMICYUC in the departments of Intensive Care Medicine in Spain

Introducción: En los servicios de Medicina Intensiva (SMI) se realizan múltiples intervenciones a los pacientes críticos. Nuestros objetivos son conocer la presencia en la práctica diaria de los SMI de elementos relacionados con los 6 indicadores de calidad en Bioética de la Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias y la participación de sus miembros en los comités de ética asistencial. Material y métodos: Estudio observacional multicéntrico mediante encuesta que estudia aspectos descriptivos de los SMI, plantea 25 cuestiones relacionadas con los indicadores de calidad bioéticos y describe la participación de miembros del SMI en los comités de ética asistencial. Los SMI se clasifican por tamaño (mayor/menor de 10 camas) y tipo de hospital (público/privado-concertado, docente/no docente). Resultados: En las 68 encuestas analizadas encontramos: información familiar diaria (97%), efectuada en sala de información (82%); protocolos de cuidados al final de vida (44%); formulario de limitación de tratamiento de soporte vital (48,43%); protocolo de contención (40%). El cumplimiento del proceso de consentimiento informado es: traqueostomía (92%), intervención vascular (76%), depuración extrarrenal (25%). La presencia actual de miembros del SMI en el Comité de Ética es frecuente (69%). Conclusiones: La información a familiares es adecuada, aunque hay SMI sin sala de información. El cumplimiento del proceso de consentimiento informado de varios procedimientos es insuficiente. La participación de miembros del SMI en los comités de ética asistencial es frecuente. Los resultados evidencian margen de mejora en la calidad bioética de los SMI (AU)

Introduction: Multiple interventions are performed in critical patients admitted to Intensive Care Units (ICUs). This study explores the presence in the daily practice of ICUs of elements related to the 6 bioethics quality indicators of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units, and the participation of their members in the hospital ethics committees. Materials and methods: A multicenter observational study was carried out, using a survey exploring descriptive aspects of the ICUs, with 25 questions related to bioethics quality indicators, and assessing the participation of ICU members in the hospital ethics committees. The ICUs were classified by size (larger or smaller than 10 beds) and type of hospital (public/private-public concerted center, with/without teaching). Results: The 68 analyzed surveys revealed: daily informing of the family (97%), carried out in the information room (82%); end-of-life care protocols (44%); life support limitation form (48.43%); and physical containment protocol (40%). Compliance with the informed consent process referred to different procedures is: tracheostomy (92%), vascular procedures (76%), and extrarenal clearance (25%). The presence of ICU members in the hospital ethics committee is currently frequent (69%). Conclusions: Information supplied to relatives is adequate, although there are ICUs without an information room. Compliance with the informed consent requirements of various procedures is insufficient. The participation of ICU members in the hospital ethics committees is frequent. The results obtained suggest a chance for improvement in the bioethical quality of the ICU (AU)

[URINARY TRACT INFECTIONS IN PATIENTS WITH URINARY CATHETERIZATION WHO SUFFER NEUROLOGICAL DISORDERS. STUDY OF THE POSSIBLE CAUSES]. / Infecciones de orina en pacientes sondados con patología neurológica. ESTUDIO DE LAS POSIBLES CAUSAS.

UNLABELLED: In previous studies carried out in our hospital (Hospital de Cabueñes, Gijón, Spain) it could be noticed/stated that every year there was a considerable difference between the patients with urine catheterization in the Neurology Service and the patients in the other hospital wards. This encourages us to carry out the following research. OBJECTIVES: The purpose of this study is to determine the causes that increase the urinary infections in neurological patients with bladder catheterization compared to catheterized patients with other diseases. Analysis of sediment and urine culture before and after the urinary bladder catheterization. METHODS. Retrospective, descriptive and observational study of fifty patients with neurological disorders who were hospitalized in the neurological care unit of Hospital de Cabueñes (Gijón, Spain) and who needed urinary catheterization. The fieldwork consisted of collecting a sample for sediment and culture before and after the urinary catheterization and also of registering the causes of the catheterization, the length of the treatment, age and sex of patients on a medical record sheet. Patients who were catheterized in the Emergency (A&E) unit, those who were taking antibiotics and those who did not suffer a neurological disease did not take part in this study. RESULTS: 20 patients (40%) out of the 50 who took part in this study and who needed urinary catheterization (UC) suffered from urinary retention, another 20 (40%) were under medical diagnosis and supervision and the last 10 (20%) were treated with manitol. 44 patients (88%) were diagnosed with strokes. 12% of them had a positive culture prior to UC placement. CONCLUSIONS: Patients who suffered stokes have a high risk of urine retention due to their functional disability. Some of them had already the urine values altered, they even had infection prior to the urinary catheter placement.

Valor pronóstico de los niveles plasmáticos de sTREM-1 en pacientes con sepsis: un estudio de cohortes / Prognostic value of the sTREM-1 plasma values in patients with sepsis: A cohort study

Objetivo: Evaluar la asociación entre los niveles plasmáticos de soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) y la mortalidad de los pacientes con sepsis. Diseño: Estudio de cohortes prospectivo. Ámbito: Dos unidades de cuidados intensivos generales. Pacientes: Pacientes con sepsis en los que se determinaron los niveles plasmáticos de sTREM-1 durante los 3 primeros días de su presentación. Variables de interés principales: Mortalidad a los 28 días. Resultados: Se analizaron 121 pacientes (el 23% sepsis grave, el 44% shock séptico y el 33% sepsis no grave). La mortalidad a los 28 días fue del 24,8%. Los niveles de sTREM-1 iniciales fueron ligeramente más elevados en los fallecidos que en los supervivientes (mediana de 366,9 frente a 266,5pg/ml; p=0,2668). Una elevación de los niveles de sTREM-1 a lo largo de los 3 primeros días (delta-TREM) superior a 90pg/ml se asoció con un exceso de mortalidad (hazard ratio: 2,68; p=0,0047), con una sensibilidad del 47% y una especificidad del 78%. Este exceso de mortalidad de los pacientes desapareció al ajustar para gravedad mediante análisis de Cox (hazard ratio ajustado de 1,07; p=0,8665). Conclusiones: En pacientes críticos con sepsis, el aumento de los niveles de sTREM-1 a lo largo de los 3 primeros días de evolución se asocia con un exceso de mortalidad, que se explica por la mayor gravedad inicial de estos pacientes. La capacidad discriminativa de este hallazgo es insuficiente para ser útil en la clínica (AU)

Objective: To evaluate the association between plasma levels of soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1) and mortality of patients with sepsis. Design: Prospective cohort study. Setting: Two general Intensive Care Units. Patients: Patients with sepsis in whom sTREM-1 plasma levels were determined daily in the first 3 days of their presentation. Variables of interest: Mortality at 28 days. Results: We analyzed 121 patients (23% severe sepsis, 44% septic shock, 33% non-severe sepsis). Mortality at 28 days was 24.8%. The initial sTREM-1 levels were slightly higher in nonsurvivors than in survivors (median 366.9 versus 266.5pg/ml, p=0.2668). An increase in sTREM-1 levels higher than 90pg/ml within the first 3 days (delta-TREM) was associated with an excess of mortality (hazard ratio [HR] 2.68, p=0.0047), with a sensitivity of 47% and a specificity of 78%. This excess of mortality disappeared after adjusting for severity by Cox analysis (adjusted HR 1.07, p=0.8665). Conclusions: The increase in the levels of sTREM-1 during the first 3 days of evolution is associated with an excess of mortality in critically ill patients with sepsis. This is explained by the greater initial severity of these patients. The discriminative capacity of this finding is insufficient to be clinically useful (AU)

Galactorrea e hiperprolactinemia en una mujer en tratamiento con anticonceptivos / Galactorrhea and hyperprolactinemia in a woman under contraceptive treatment

Un 20-25% de las mujeres tiene galactorrea en algún momento de su vida. Es una situación clínica que debe manejar el médico de Atención Primaria. La secreción elevada de prolactina es una causa frecuente de galactorrea. La clínica típica de la hiperprolactinema es la presencia de infertilidad, oligoamenorrea y galactorrea. Describimos un caso clínico que es interesante en varios aspectos. Los niveles de prolactina sérica pueden ser orientativos de la causa de la hiperprolactinemia. El manejo de las elevaciones poco importantes de la prolactina es muchas veces conservador, retirando medicación y con pruebas de imagen y de laboratorio espaciadas. La coincidencia de hiperprolactinemia y lesión identificable en una prueba de imagen no siempre es indicativa de adenoma secretor de prolactina (AU)

About 20-25% of women suffer galactorrhea at some timein their lives. It is a clinical situation that should be treatedby the Primary Care physician. Elevated secretion of prolactinis a frequent cause of galactorrhea. The typical symptomsof hyperprolactinema are presence of infertility, oligoamenorrheaand galactorrhea. We describe a clinical case that isof interest in several aspects. The serum prolactin levels maybe orientative of the cause of the hyperprolactinemia. Managementof the unimportant elevations of prolactin is oftenconservative, withdrawing medication and with imagingtests and spaced laboratory tests. Coincidence of hyperprolactinemiaand identifiable lesion in an imaging test is not alwaysindicative of prolactin secretory adenoma (AU)

[Improvement of child survival in Mexico: the diagonal approach]. / Aumento de la sobrevida en menores de cinco años en México: la estrategia diagonal.

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.

Aumento de la sobrevida en menores de cinco años en México: la estrategia diagonal / Improvement of child survival in Mexico: the diagonal approach

Las intervenciones en salud pública dirigidas a niños en México han ubicado a este país entre los siete países encaminados a cumplir las metas de reducción de la mortalidad infantil para 2015. La información para este estudio se ha tomado de diferentes fuentes: los censos poblacionales; los registros de mortalidad de la Secretaría de Salud y del Instituto Nacional de Estadística, Geografía e Informática; el registro nominal de niños recolectado por el Programa de Vacunación Universal; y las encuestas nacionales de nutrición. Con estos datos se estudió la asociación temporal y la plausibilidad biológica de las diferentes intervenciones en salud pública, para explicar la reducción de las tasas de mortalidad entre niños, infantes y recién nacidos. Las tasas de mortalidad en menores de cinco años han descendido de casi 64 muertes a menos de 23 por cada 1 000 niños nacidos vivos registrados en los últimos 25 años. Se observó una reducción drástica en las tasas de mortalidad por diarrea, junto con la eliminación de polio, difteria y sarampión. El estado nutricional de los niños mejoró de manera significativa en cuanto a bajo peso para la talla, baja talla para la edad y bajo peso para la edad. En los últimos 25 años, se mantuvieron intervenciones altamente costo-efectivas que acercaron los servicios de salud de atención primaria a los hogares, lo que aquí se ha llamado estrategia diagonal. A pesar de que no es posible establecer una relación de causalidad entre la reducción de la mortalidad en menores de cinco años y los factores investigados, se presenta evidencia basada en la asociación temporal y en la plausibilidad biológica que indica que la alta cobertura de las intervenciones de salud pública, los avances en educación de las mujeres, protección social, disponibilidad de agua potable y saneamiento, así como nutrición, impactaron en el resultado observado. Por otro lado, el liderazgo y la continuidad de las políticas de salud pública junto...

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.

Salmonella enterica serovar Enteritidis producing a TEM-52 beta-lactamase: first report in Spain.

TEM-52 is an extended-spectrum beta-lactamase (ESBL) that is being increasingly reported in enterobacteria. In Spain, TEM-52 had been reported before only in Escherichia coli. Here we report the first finding of a TEM-52 ESBL in Salmonella in Spain, associated to a Tn3 transposon.

Changes in the geographical distribution of tuberculosis patients in Veracruz, Mexico, after reinforcement of a tuberculosis control programme.

OBJECTIVE: Geographical information systems are valuable tools for studying tuberculosis (TB) epidemiology, but have been underused for the evaluation of TB control programs. We aimed to compare the geographical distribution of TB before and after the five elements of directly observed therapy, short course (DOTS) were strengthened in a Health Jurisdiction in Mexico in response to recommendations made by the WHO Global Tuberculosis Program. METHODS: All consenting persons detected by passive case finding between March 1995 and February 2000 who were confirmed to have acid-fast bacilli (AFB) in sputum underwent clinical and laboratory evaluation. A TB 'episode' was defined as the period of time between bacteriological diagnosis and treatment discharge by the local control programme. Distances of TB episodes from the nearest urban centre were determined according to recent transmission and multidrug resistance (MDR). RESULTS: During the first half of the study period, MDR episodes were located a median distance of 1.24 km from urban centres, which did not differ significantly from non-MDR episodes (1.14 km, P=0.56). In contrast, the median distance of MDR episodes increased 55% to 1.92 km during the second half, which placed them significantly further away out than non-MDR episodes (1.08 km, P=0.01). No changes in location were detected for recent transmission. CONCLUSION: While reinforcing the TB control programme reduced the incidence of MDR, the remaining episodes were located in poorer and more remote areas.

[Nosocomial gastroenteritis and asymptomatic rotavirus and astrovirus infection in hospitalized children]. / Gastroenteritis aguda nosocomial e infección asintomática por rotavirus y astrovirus en niños hospitalizados.

BACKGROUND: Nosocomial gastroenteritis is frequent in pediatric hospital wards. Between 20% and 50% of gastroenteritis cases caused by rotavirus and astrovirus are of nosocomial origin. OBJECTIVE: To determine the incidence of nosocomial rotavirus and astrovirus gastroenteritis in our environment, the incidence of asymptomatic infection with these viruses, and to identify the G serotypes of the rotaviruses detected. METHODS: We performed a prospective study of all children under 2 years of age admitted to a neonatology unit over a 1-year period who were followed-up for the presence of diarrhea and periodic study of feces to detect the presence of rotavirus and astrovirus antigens by enzyme immunoassay (EIA). Patients with gastroenteritis also underwent bacteria stool culture, adenovirus detection by EIA, calcivirus detection by polymerase chain reaction, and analysis of rotavirus G serotypes by EIA with monoclonal antibodies. RESULTS: Of 666 children admitted without diarrhea, 60 presented nosocomial gastroenteritis (9 % of patients admitted and 1.75 per 100 days of hospital stay): 34 presented rotavirus (5 % of patients) and two presented astrovirus (0.3 % of patients). Of the 329 patients without diarrhea who were studied, viral elimination was detected in 27: rotavirus in 23 patients and astrovirus in four. Viral infection was detected on admission in 13 patients (4 %) and after 72 hours in 14 patients (4.2 %) (asymptomatic nosocomial infection). No differences in the distribution of rotavirus G serotypes were observed between community-acquired and nosocomial gastroenteritis. CONCLUSIONS: These data confirm the importance of viral etiology in nosocomial gastroenteritis and allow us to evaluate asymptomatic fecal elimination of rotavirus as one of the factors in the transmission of this infection.

Immunologic studies of specific mucosal and systemic immune responses in Mexican school children after booster aerosol or subcutaneous immunization with measles vaccine.

The purpose of the present study was to compare serum and mucosal immune responses following either aerosol (Aer) or subcutaneous (SQ) measles immunization of Mexican school children. A cohort of 49 children from 6 to 7 years of age received either Aer ( n = 22) or SQ ( n = 27) Edmonston-Zagreb (EZ) measles vaccine. Serum and nasal secretions were collected prior to (Pre), 1 and 3 months (mos) intervals and analyzed for immunoglobulin (Ig) concentrations and measles specific Ig isotype-associated antibody by enzyme immunoassay (EIA). Serum and nasal IgG and IgA antibody responses were stimulated following immunization with live, attenuated EZ measles vaccine administered either by SQ or Aer routes but these responses were significantly greater by the Aer compared to the SQ route. These studies also suggest that the level of antibody in these secretions may serve as an important marker of immunity to measles and lend further support for aerosol immunization as an effective alternative vaccine delivery strategy for measles eradication.

Aerosolized measles and measles-rubella vaccines induce better measles antibody booster responses than injected vaccines: randomized trials in Mexican schoolchildren.

OBJECTIVE: To compare antibody responses and side-effects of aerosolized and injected measles vaccines after revaccination of children enrolling in elementary schools. METHODS: Vaccines for measles (Edmonston-Zagreb) or measles-rubella (Edmonston-Zagreb with RA27/3) were given by aerosol or injection to four groups of children. An additional group received Schwarz measles vaccine by injection. These five groups received vaccines in usual standard titre doses. A sixth group received only 1000 plaque-forming units of Edmonston-Zagreb vaccine by aerosol. The groups were randomized by school. Concentrations of neutralizing antibodies were determined in blood specimens taken at baseline and four months after vaccination from randomized subgroups (n = 28-31) of children in each group. FINDINGS: After baseline antibody titres were controlled for, the frequencies of fourfold or greater increases in neutralizing antibodies did not differ significantly between the three groups that received vaccine by aerosol (range 52%-64%), but they were significantly higher than those for the three groups that received injected vaccine (range 4%-23%). Mean increases in titres and post-vaccination geometric mean titres paralleled these findings. Fewer side-effects were noted after aerosol than injection administration of vaccine. CONCLUSION: Immunogenicity of measles vaccine when administered by aerosol is superior to that when the vaccine is given by injection. This advantage persists with aerosolized doses less than or equal to one-fifth of usual injected doses. The efficacy and cost-effectiveness of measles vaccination by aerosol should be further evaluated in mass campaigns.

A continuous flow system design for simultaneous determination of heavy metals in river water samples.

A new design of a continuous flow system applied to the simultaneous determination of the concentration of zinc(II), cadmium(II), lead(II), copper(II), nickel(II), cobalt(II) and chromium(VI) in river water is described. A flow cell made in the laboratory, which has been patented, based on a 'wall-jet' configuration with a three-electrode system is described. Optimum conditions for the determination of the metal ions are reported. The detection limits and relative standard deviation values were 4.01x10(-9) M and 0.078 for Zn(II), 1.76x10(-10) M and 0.056 for Cd(II), 4.69x10(-10) M and 0.134 for Pb(II), 2.29x10(-10) M and 0.138 for Cu(II), 1.61x10(-9) M and 0.093 for Ni(II), 1.91x10(-9) M and 0.113 for Co(II), and 1.35x10(-9) M and 0.081 for Cr(VI). The procedure was applied to a sample of water from the Arlanzón river and the results were compared with inductively coupled mass plasma spectrometry (ICP-MS) as reference method. The final aim of this work is to design a flow system, which can be automated.