Satisfaction in the Intensive Care Unit (ICU). Patient opinion as a cornerstone. / Satisfacción en la Unidad de Cuidados Intensivos (UCI): la opinión del paciente como piedra angular.

OBJECTIVE: To study the agreement between the level of satisfaction of patients and their families referred to the care and attention received during admission to the ICU. DESIGN: A prospective, 5-month observational and descriptive study was carried out. SETTING: ICU of Marqués de Valdecilla University Hospital, Santander (Spain). SUBJECTS: Adult patients with an ICU stay longer than 24h, who were discharged to the ward during the period of the study, and their relatives. INTERVENTION: Instrument: FS-ICU 34 for assessing family satisfaction, and an adaptation of the FS-ICU 34 for patients. The Cohen kappa index was calculated to assess agreement between answers. RESULTS: An analysis was made of the questionnaires from one same family unit, obtaining 148 pairs of surveys (296 questionnaires). The kappa index ranged between 0.278-0.558, which is indicative of mild to moderate agreement. CONCLUSIONS: The families of patients admitted to the ICU cannot be regarded as good proxies, at least for competent patients. In such cases, we must refer to these patients in order to obtain first hand information on their feelings, perceptions and experiences during admission to the ICU. Only when patients are unable to actively participate in the care process should their relatives be consulted.

[Analysis of subdural intracraneal empyemas in a third level hospital]. / Análisis de los empiemas subdurales intracraneales en un hospital de tercer nivel.

INTRODUCTION: Intracranial subdural empyema (ISE) is an infrequent infectious disorder of diverse etiology and difficult to diagnose because of its non-specific clinical features. PATIENTS AND METHODS: Retrospective study of patients diagnosed of ISE in a third-level university hospital in a 15-year period. RESULTS: Five men were included (mean age: 39.3 years). The most frequent primary source of infection was otic and sinusal (60%). The initial clinical manifestations were fever, headache, alteration of consciousness, and neurological focal symptoms. The mean time elapsed between onset of symptoms and diagnosis was 3.6 days. Diagnosis was performed by computed tomography in all patients. ISE was localized in the left hemisphere in 60% of cases mainly affecting the parietal lobe (80%). Anaerobic and streptococci germs were the most frequently isolated microorganisms. Therapy was based on antibiotics and surgical drainage in 100% of the cases. The surgical procedure used in the evacuation of empyema was craniotomy in all the patients. The mean time elapsed between diagnosis and surgery was 8.4 days. The mean Intensive Care Unit stay was 12.8 days, whereas the overall mean in-hospital stay was 45.2 days. Mortality was 40%. CONCLUSION: ISE, although infrequent, displays a high morbimortality that can be reduced with an early therapeutic approach which may include the surgical evacuation in all the cases.

[Complications of the cannulation of a central venous line]. / Complicaciones de la canalización de una vía venosa central.

Central venous catheters are essential in modern-day medical practice, particularly in intensive care units. Although such catheters provide necessary vascular access, their use puts patients at risk of mechanical and infectious complications. Unfortunately, these complications are associated with an increase of the morbidity-mortality, lengthen hospitalization and raise medical costs. Strategies should be implemented to reduce the incidence of these complications to improve clinical outcome and reduce health-care costs.

Hydroxyapatite-coated stems with metaphyseal and diaphyseal press-fit. Eleven-year follow-up results.

We report the 11-year follow-up results of 52 unilateral primary hip arthroplasties performed with hydroxyapatite-coated stems. The femoral prosthesis used was a collarless titanium alloy implant, with proximal circumferential hydroxyapatite coating and increased distal thickness to fit the proximal diaphyseal region of the femur. Clinical evaluation was performed using the Merle d'Aubigné Hip Score. Anteroposterior and lateral radiographs were obtained and compared with previous postoperative films. Radiographic evaluation was carried out following Engh's criteria for uncemented implant fixation and using Livermore's method for measurement of polyethylene wear. At the end of the follow-up period, excellent and good clinical results were recorded in 40 arthroplasties (77%). The incidence of thigh pain at one year was 32.7%, but it decreased to 4.2% after the first post-operative year. The 11-year survival rate was 92.3%. Seven arthroplasties were revised because of aseptic loosening of the cup in one case, aseptic loosening of the stem, in one case, septic loosening of the stem in one case, periprosthetic fracture in two cases and polyethylene wear in three cases. Forty-two (87.5%) of the nonrevised stems met the criteria for radiographic osseointegration. Cortical hypertrophy was observed around the mid-part and tip of the stem in 22 patients of the series. This sign tends to be related to thigh pain (p < 0.1). Calcar osteolysis was present in 8 cases. There was only one case of distal femoral osteolysis. We found a strong and significant relationship between long-term wear rates and the occurrence of osteolysis (p < 0.001). We concluded that thigh pain is in relation to the distal diameter of the stems and significantly decreases after the first postoperative year. There was a low incidence of osteolysis in our series in comparison with other series of noncemented implants with 32-mm femoral heads and with similar follow-up.

[Conservative management versus osteosynthesis in the treatment of tibial shaft fractures]. / Konservative Versorgung versus Osteosynthese in der Behandlung der Unterschenkelschaftbrüche.

Treatment was rendered to 1,693 patients with 1,728 tibial shaft fractures at the University Hospital of Granada, Spain, between 1971 and 1987. After 139 patients had died, 1,554 patients with 1,571 tibial fractures were actually left for treatment. Forms of fractures were subdivided according to Johner and Wruhs. Conservative treatment, according to Böhler-Sarmiento, was applied to 589 cases, while surgery was performed on 982. Different ways of osteosynthesis were used, including tibial plates (n = 284), intramedullary nailing according to Küntscher (n = 308), and lock nailing according to Klemm (n = 336). Other methods of osteosynthesis, such as elastic nailing according to Ender (n = 36) and external fixation (n = 18) were rarely used and, therefore, were not statistically evaluated. --The author's result have provided evidence to the effect that conservative treatment according to Böhler (and modified by Sarmiento) worked well, with only 11.4 per cent complications in cases of closed and open fractures. However, only moderate results were obtained from follow-up checks, since compensation was usually not possible for the majority of primary lateral fragment displacements, so that for consolidation limbs had to be kept immobilised for much longer periods of time, and this entailed poor functional results. --Very poor results were obtained from plate osteosynthesis, in the context of surgical treatment, with the rate of complications being as high as 34.9 per cent. Better results were achieved by intramedullary nailing, with complications in 14.9 per cent of all cases. Yet, it is the author's view that lock nailing has become the established optional method.