RESUMO
Una buena gestión y calidad de la Formación Sanitaria Especializada (FSE) exige el compromiso explícito de los responsables de las CCAA y de los centros sanitarios. Esto implica la acreditación y reconocimiento de tutores, desarrollar el marco normativo que establece el RD 183/2008 (a los nueve años de su publicación sólo Cataluña, Canarias, Castilla y León, Extremadura, La Rioja y el País Vasco, lo han hecho), una mención explícita de la FSE en los planes estratégicos de las organizaciones sanitarias y en los contratos-programa con las unidades docentes y una participación activa de los jefes de estudio en los consejos de dirección de los centros. Por parte del Ministerio de Sanidad, es preciso agilizar la acreditación de las nuevas unidades docentes y abordar, junto con las CCAA, los problemas de financiación del proyecto de troncalidad y la organización de las unidades docentes troncales. Respecto al sentido de la formación, esta se ha de centrar en la seguridad del paciente, aquí la simulación es una metodología formativa idónea, y en la humanización, con una práctica de la medicina bajo un modelo deliberativo, siendo los formadores ejemplo para los que aprenden
The commitment of the heads of the Autonomous Communities and the health centers is key to a good management and the quality of the Specialized Healthcare Training (SHT). This implies the accreditation and recognition of tutors, developing the regulatory framework established by Royal Decree 183/2008 (nine years after its publication, only Catalonia, the Canary Islands, Castilla y León, Extremadura, La Rioja and the Basque Country have done so), an explicit mention of the SHT in the strategic plans of the health organizations and an active participation of the heads of SHT in the boards of directors. On the part of the Ministry of Health, it is necessary to speed up the accreditation process of new teaching units and, together with the Autonomous Communities, and address the financing problems of the core curriculum project and the organization of the core teaching units. Regarding the sense of training, this has to focus on safety patient, here the simulation is a suitable training methodology, and in the humanization, with a practice of medicine under a deliberative model, being the trainers an example for those who learn
Assuntos
Humanos , Fóruns de Discussão , Mentores/legislação & jurisprudência , Educação Médica/legislação & jurisprudência , Acreditação/normas , Educação Médica/normas , Grupos Focais/normasRESUMO
BACKGROUND AND OBJECTIVE: Even though atherosclerosis is a systemic disease, few prospective studies have evaluated in a thorough and systematic manner the whole vascular tree in patients with clinical damage of different territories. PATIENTS AND METHOD: Prospective protocolized study of 269 consecutive patients younger than 70, attended because of symptomatic arteriosclerosis of any territory -53% coronary (CHD), 32% cerebrovascular (CVD), 15% peripheral (PVD)-. Patients underwent evaluation of risk factors and their control, systematic non-invasive study of the vascular tree (Doppler-ultrasound) and comparison between groups according to the index territory. RESULTS: Even though all risk factors were represented in the 3 groups, male sex, smoking and diabetes were more frequent in PVD and dyslipemia was more common in CHD (p < 0.05) Abdominal aortic diameter and carotid intima-media thickness were similar for all groups, while the number of carotid plaques was higher in PVD. CHD patients more often presented left ventricular hypertrophy and reduced ejection fraction. PVD patients showed a marked reduction of the ankle-brachial index as well as increased C-reactive protein and homocysteine (p < 0.05). Severe unsuspected vascular lesions were found in 13% of cases (95% confidence interval, 9.5-17.6%). Risk factor control was better for CHD, followed by CVD and PVD, but was globally poor. CONCLUSIONS: The systematic evaluation of the vascular tree detects generalized atherosclerotic lesions, in some cases severe and clinically unsuspected. New markers to identify patients at very high risk are necessary. Peripheral vascular disease identifies a group of patients of particular risk. Risk factor control is deficient, particularly among PVD patients.
Assuntos
Arteriosclerose/diagnóstico por imagem , Arteriosclerose/epidemiologia , Idoso , Antropometria , Aterosclerose/diagnóstico por imagem , Aterosclerose/epidemiologia , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Feminino , Humanos , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/epidemiologia , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/diagnóstico por imagem , Doenças Vasculares Periféricas/epidemiologia , Estudos Prospectivos , Fatores de Risco , UltrassonografiaRESUMO
Fundamento y objetivo: Aunque la aterosclerosis es una enfermedad generalizada del árbol vascular, existen escasos estudios prospectivos que evalúen transversalmente de modo extenso a pacientes con afectación clínica de diferentes territorios. Pacientes y método: Se ha realizado un estudio prospectivo protocolizado de 269 pacientes consecutivos menores de 70 años atendidos por aterosclerosis sintomática de cualquier territorio en un 53% coronario (CI), en un 32% cerebral (VC) y en un 15% periférico (VP). Se evaluaron los factores de riesgo y su control, y se realizó un estudio sistemático no invasivo del árbol vascular (ecografía Doppler) con una comparación entre los grupos según el territorio índice. Resultados: Aunque todos los factores de riesgo estaban representados en los 3 grupos, el sexo masculino, el tabaquismo y la diabetes fueron más frecuentes en VP y la dislipemia en CI (p < 0,05). El diámetro de la aorta abdominal y el grosor carotídeo mediointimal fueron similares en los 3 grupos, si bien el número de placas carotídeas fue superior en VP. CI presentó más frecuentemente hipertrofia ventricular y disminución de la fracción de eyección. VP presentó un índice tobillo-brazo notablemente inferior, junto con valores más elevados de proteína C reactiva y homocisteína (p < 0,05). Se descubrieron lesiones vasculares graves no sospechadas en un 13% de los pacientes (intervalo de confianza del 95%, 9,5-17,6%). El control de los factores de riesgo fue mejor en CI, seguido por VC y VP, si bien globalmente fue deficiente. Conclusiones: El estudio sistemático del árbol vascular detecta lesiones aterosclerosas generalizadas, no sospechadas clínicamente, en algunos casos graves. Son necesarios marcadores que permitan identificar a los pacientes de muy alto riesgo. La enfermedad vascular periférica identifica a un grupo de pacientes de especial riesgo vascular. El grado de control de los factores de riesgo es deficiente, especialmente en VP
Background and objective: Even though atherosclerosis is a systemic disease, few prospective studies have evaluated in a thorough and systematic manner the whole vascular tree in patients with clinical damage of different territories. Patients and method: Prospective protocolized study of 269 consecutive patients younger than 70, attended because of symptomatic arteriosclerosis of any territory 53% coronary (CHD), 32% cerebrovascular (CVD), 15% peripheral (PVD). Patients underwent evaluation of risk factors and their control, systematic non-invasive study of the vascular tree (Doppler-ultrasound) and comparison between groups according to the index territory. Results: Even though all risk factors were represented in the 3 groups, male sex, smoking and diabetes were more frequent in PVD and dyslipemia was more common in CHD (p < 0.05) Abdominal aortic diameter and carotid intima-media thickness were similar for all groups, while the number of carotid plaques was higher in PVD. CHD patients more often presented left ventricular hypertrophy and reduced ejection fraction. PVD patients showed a marked reduction of the ankle-brachial index as well as increased C-reactive protein and homocysteine (p < 0.05). Severe unsuspected vascular lesions were found in 13% of cases (95% confidence interval, 9.5-17.6%). Risk factor control was better for CHD, followed by CVD and PVD, but was globally poor. Conclusions: The systematic evaluation of the vascular tree detects generalized atherosclerotic lesions, in some cases severe and clinically unsuspected. New markers to identify patients at very high risk are necessary. Peripheral vascular disease identifies a group of patients of particular risk. Risk factor control is deficient, particularly among PVD patients
Assuntos
Masculino , Feminino , Idoso , Humanos , Arteriosclerose/epidemiologia , Arteriosclerose , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana , Arteriosclerose Intracraniana/epidemiologia , Arteriosclerose Intracraniana , Estudos Prospectivos , Fatores de Risco , AntropometriaRESUMO
La limitación de esfuerzos terapéuticos es una medida escasamente evaluada en nuestro medio. Se valoran las características de los pacientes en los que se retiran los antibióticos en presencia de una infección activa. Se recogieron datos de todos los pacientes ancianos ingresados consecutivamente en medicina interna con infección activa a los que se les suspendía el antibiótico. Se compararon las características de los pacientes que fallecieron y de los que no. En el estudio se incluyó a 63 pacientes (8,9% de los ingresos); 84,6 ± 9,1 años. Un 86% tenía demencia, un 73%, incapacidad, y un 30%, neoplasia activa. El motivo de la retirada de los antibióticos fue siempre la percepción de una muerte cercana y/o la falta de respuesta al tratamiento. La mortalidad fue del 89%. Entre los que fallecieron, predominó el sexo femenino (el 95 frente al 76%) y tanto el tiempo sin antibiótico (2,9 frente a 8,5 días) como la estancia media (9,6 frente a 16,0 días) fueron más breves (p < 0,05). La suspensión del antibiótico es una medida no infrecuente en nuestro medio y está concentrada en pacientes con mal pronóstico vital y mala situación previa
Limitation of therapy has been little studied in our environment. Data were gathered on all patients with active infection consecutively admitted to the internal medicine department of our hospital in whom antibiotic therapy was withdrawn or withheld. The characteristics of patients who died and those of patients who survived were compared. A total of 63 patients (8.9% of admissions) were included; the mean age was 84.6 years ± 9.1. Dementia was present in 86%, incapacity in 73% and neoplasms in 30%. In all patients, the reason for withdrawing or withholding antibiotic treatment was the perception of impending death and/or lack of response to active treatment. In all patients, the families were involved in the decision to forego treatment. Mortality was 89%. Female sex was more common (95% versus 76%) and length of stay (9.6 versus 16.0 days) and time without antibiotic treatment (2.9 versus 8.5 days) were shorter in patients who died than in the group who survived. The decision to forego antibiotic treatment is not infrequent in our hospital. Most patients were elderly, had diseases with poor vital prognosis, and showed poor prior health status
Assuntos
Idoso , Humanos , Atitude Frente a Morte , Atitude do Pessoal de Saúde , Tomada de Decisões , Assistência Terminal , Suspensão de Tratamento , Antibacterianos , Infecções/mortalidade , Estudos ProspectivosRESUMO
BACKGROUND: This study investigates the clinical use of neuroleptics within a general hospital in acutely ill medical or surgical patients and its relation with dementia three months after admission compared with control subjects. METHODS: Cases were defined as every adult patient to whom a neuroleptic medication was prescribed during their hospitalization in our Hospital from February 1st, to June 30th, 1998. A control matched by age and sex was randomly selected among patients who had been admitted in the same period, in the same department, and had not received neuroleptics drugs (205 cases and 200 controls). Demographic, clinical and complementary data were compared between cases and controls. Crude odds ratios estimating the risk of dementia in non previously demented subjects compared with the risk in non-demented control subjects were calculated. RESULTS: 205 of 2665 patients (7.7%) received a neuroleptic drug. The mean age was 80.0 +/- 13.6 years and 52% were females. They were older and stayed longer than the rest of the population. Only 11% received a psychological evaluation before the prescription. Fifty two percent were agitated while 40% had no reason justifying the use of neuroleptic drug. Three months after neuroleptic use 27% of the surviving cases and 2.6% of the surviving controls who were judged non-demented at admission were identified as demented. CONCLUSIONS: The most common reason for neuroleptic treatment was to manage agitation symptomatically in hospitalised patients. Organic mental syndromes were rarely investigated, and mental status exams were generally absent. Most of neuroleptic recipients had either recognised or unrecognised dementia.
