Posible enfermedad por IgG4 asociada con alogenosis iatrogénica. Caso clínico / Possible IgG4 disease associated with iatrogenic allogeneic disease. Case report

Presentamos un caso de paciente con alogenosis iatrogénica que tras ser intervenido quirúrgicamente, cursa con pancreatitis aguda de etiología no precisada con valores séricos elevados de inmunoglobulina 4 (IgG4). La asociación con la buena respuesta terapéutica al tratamiento esteroideo unida al antecedente de síndrome autoinmune inflamatorio sistémico inducido por adyuvantes, insuficiencia renal crónica con biopsia que reportó atrofia tubular severa con fibrosis, pseudotumores intestinales, pérdida de peso, diarrea y dolores óseos asociados, hizo pensar que el agente desencadenante de la respuesta inmunológica pudo ser el estímulo que elevó la IgG4 sérica llevando al diagnóstico de posible enfermedad relacionada con IgG4.(AU)

We present a case with iatrogenic allogenosis who, after undergoing surgery, presented acute pancreatitis of unspecified etiology with elevated serum levels of immunoglobulin 4 (IgG4). The association with a good therapeutic response to steroid treatment coupled with a history of adjuvant-induced systemic inflammatory autoimmune syndrome, insufficiency chronic kidney disease with biopsy that reported severe tubular atrophy with fibrosis, intestinal pseudotumors, weight loss, diarrhea and associated bone pain, suggested that the immunogenic agent that triggers the immune response could be the stimulus to raise serum IgG4 leading to the diagnosis of possible IgG4 disease.(AU)

Cierre de fístula traqueocutánea recidivante / Closure of Recurrent Tracheocutaneous Fistula

Introducción: La fístula traqueocutánea es la complicación más frecuente de la traqueostomía, que lleva a la necesidad de usar diferentes tipos de plastias para lograr un cierre definitivo. Objetivo: Mostrar una opción de tratamiento quirúrgico para garantizar un cierre definitivo de la fístula traqueocutánea recidivante. Caso clínico: Se presenta paciente masculino de 45 años con antecedentes de traqueostomía sin cierre espontáneo; quien desarrolló fístula traqueocutánea tratada con doble plastia de deslizamiento frontal tipo Szymanowski, con posterior recidiva, motivo por el que acude a consulta. Se realizó cierre directo de mucosa traqueal con plicatura de músculo platisma y avance de colgajos de piel rectangulares para reforzar cobertura de la pared anterior de la tráquea. Se logró corregir la fístula mediante un procedimiento simple, rápido y efectivo. Conclusiones: Este método evita las dificultades encontradas en otros procedimientos y garantiza la corrección funcional y estética con el empleo de una técnica simple con baja morbilidad(AU)

Introduction: Tracheocutaneous fistula is the most frequent complication of tracheostomy, leading to the need to use different types of plasties to achieve a definitive closure. Objective: To show a surgical treatment option for guaranteeing a definitive closure of recurrent tracheocutaneous fistula. Clinical case: We present the case of a 45-year-old male patient with a history of tracheostomy without spontaneous closure, who developed tracheocutaneous fistula managed through double plasty of anterior sliding of Szymanowski type, followed by recurrence. Direct closure of the tracheal mucosa was performed with platysma muscle plication and advancement of rectangular skin flaps for reinforcing coverage of the anterior wall of the trachea. Correction of the fistula was achieved by a simple, fast and effective procedure. Conclusions: This method avoids the difficulties found in other procedures, and guarantees functional and aesthetic correction with the use of a simple technique with low morbidity(AU)

Case Report: COVID-19 Misdiagnosed as a Drug Reaction to Miltefosine.

We present case reports of two patients treated with miltefosine for mucocutaneous leishmaniasis whose gastrointestinal symptoms were initially diagnosed as a drug reaction and only later recognized as due to COVID-19. Gastrointestinal symptoms of COVID-19 are unusual, whereas gastrointestinal adverse drug reactions are very common. These reports exemplify that this infrequent presentation of COVID-19 is likely to be ascribed to a more common etiology such as a gastrointestinal drug reaction.

Incidence and risk factors associated with the development of pressure ulcers in an intensive care unit.

AIMS AND OBJECTIVES: To determinate the incidence, incidence rate and risk factors of pressure ulcers in critical care patients. BACKGROUND: Pressure ulcers represent one of the most frequent health problems in clinical practice. Specifically, critical patients who are hospitalised in intensive care units have a higher risk of developing a pressure ulcer, with an incidence that fluctuates between 3.3-39.3% according to previous studies. DESIGN: Prospective cohort study. METHODS: Three hundred and thirty-five adult patients (over 18 years old) who were hospitalised in intensive care units for at least 24 hr were monitored for a maximum of 32 days. They were excluded if they had a pressure ulcers at admission. The survival rate for pressure ulcers, from stages I-IV, was calculated using the Kaplan-Meier method. A multivariate Cox regression model was adjusted to identify the main risk factors for pressure ulcers: demographic, clinical, prognostic and therapeutic variables. RESULTS: The incidence of pressure ulcers in critical patients was 8.1%, and the incidence rate was 11.72 pressure ulcers for 1,000 days of intensive care units stay; 40.6% of pressure ulcers were of stage I and 59.4% of stage II, mainly in the sacrum. According to the Cox model, the main risk factors for pressure ulcers were in-hospital complications, prognostic scoring system (SAPS III) and length of immobilisation. CONCLUSIONS: The incidence of pressure ulcers is lower than that shown in recent studies. Complications on the unit and the prognosis score were risk factors associated with pressure ulcers but, surprisingly, length of immobilisation was a protective factor. RELEVANCE TO CLINICAL PRACTICE: Survival analysis of pressure ulcer allows for identification of risk factors associated with this health problem in the intensive care units. Identifying these factors can help nurses establish interventions to prevent pressure ulcers in this healthcare scenario, given that pressure ulcers prevention is an indicator of nursing quality.

Seguridad y calidad en la atención al paciente crítico / Safety and quality in critical patient care

La calidad asistencia ha ido situándose paulatinamente en el centro angular del sistema sanitario, alcanzando en los últimos años un mayor protagonismo la seguridad del paciente como una de las dimensiones clave de la calidad. La monitorización, medición y mejora de la seguridad y la calidad de la atención en la Unidad de Cuidados Intensivos representan un gran desafío para la comunidad de los cuidados críticos. Las intervenciones sanitarias conllevan un riesgo de que acontezcan eventos o acontecimientos adversos que pueden ocasionar en los pacientes lesiones, discapacidades e incluso la muerte. En las Unidades de Cuidados Intensivos, la gravedad del paciente crítico, las barreras de comunicación, la realización de un número elevado de actividades por paciente y día, la práctica de procedimientos diagnósticos y tratamientos invasivos, y la cantidad y complejidad de la información recibida, entre otros, convierten a estas unidades en áreas de riesgo para la aparición de acontecimientos adversos. En el presente artículo se abordan algunas de las estrategias e intervenciones propuestas y testadas internacionalmente para optimizar los cuidados en los pacientes críticos y mejorar la cultura de seguridad en la Unidad de Cuidados Intensivos

The care quality has gradually been placed in the center of the health system, reaching the patient safety a greater role as one of the key dimensions of quality in recent years. The monitoring, measurement and improvement of safety and quality of care in the Intensive Care Unit represent a great challenge for the critical care community. Health interventions carry a risk of adverse events or events that can cause injury, disability and even death in patients. In Intensive Care Unit, the severity of the critical patient, communication barriers, a high number of activities per patient per day, the practice of diagnostic procedures and invasive treatments, and the quantity and complexity of the information received, among others, put at risk these units as areas for the occurrence of adverse events. This article presents some of the strategies and interventions proposed and tested internationally to optimize the care of critical patients and improve the safety culture in the Intensive Care Unit

Safety and quality in critical patient care. / Seguridad y calidad en la atención al paciente crítico.

The care quality has gradually been placed in the center of the health system, reaching the patient safety a greater role as one of the key dimensions of quality in recent years. The monitoring, measurement and improvement of safety and quality of care in the Intensive Care Unit represent a great challenge for the critical care community. Health interventions carry a risk of adverse events or events that can cause injury, disability and even death in patients. In Intensive Care Unit, the severity of the critical patient, communication barriers, a high number of activities per patient per day, the practice of diagnostic procedures and invasive treatments, and the quantity and complexity of the information received, among others, put at risk these units as areas for the occurrence of adverse events. This article presents some of the strategies and interventions proposed and tested internationally to optimize the care of critical patients and improve the safety culture in the Intensive Care Unit.

A single-day point-prevalence study of faecal carriers in long-term care hospitals in Madrid (Spain) depicts a complex clonal and polyclonal dissemination of carbapenemase-producing Enterobacteriaceae.

OBJECTIVES: The objective of this study was to describe the prevalence and microbiological characteristics of carbapenemase-producing Enterobacteriaceae (CPE) colonizing patients in long-term care hospitals (LTCHs) in Madrid, Spain. METHODS: Three LTCHs were included in a single-day point-prevalence survey (September 2013). Rectal swabs, collected from all hospitalized patients (137 in LTCH-A, 121 in LTCH-B and 83 in LTCH-C), were plated onto chromogenic media. Population structure (PFGE and MLST), genes encoding carbapenemases and ESBLs and plasmids carrying carbapenemase genes were characterized. RESULTS: The prevalence of CPE carriers was 4.1% (14/341) [2.9% (4/137), LTCH-A; 4.1% (5/121), LTCH-B; and 6.0% (5/83), LTCH-C]. OXA-48 was the most prevalent carbapenemase (nine Klebsiella pneumoniae, two Escherichia coli, one Enterobacter cloacae and one Citrobacter braakii) followed by VIM-1 (one K. pneumoniae and one Raoultella ornithinolytica). One patient (LTCH-C) was co-colonized with OXA-48-producing K. pneumoniae and E. coli. K. pneumoniae and E. coli isolates also coproduced CTX-M-15 (n = 11) or CTX-M-9 (n = 1) enzymes. K. pneumoniae clustered into six PFGE types corresponding to ST11 (n = 1), ST15 (n = 6), ST307 (n = 1) and ST405 (n = 2). E. coli from LTCH-A and LTCH-C exhibited two different PFGE types associated with ST68. OXA-48 and VIM-1 enzymes were found in different clones in LTCH-A and LTCH-C. However, OXA-48 was the only carbapenemase detected in LTCH-B, mainly associated with K. pneumoniae ST15. KPC, IMP and NDM enzymes were not detected. blaOXA-48 was located on an ∼ 60 kb plasmid with a pOXA-48a-IncL/M backbone. CONCLUSIONS: We describe the first point-prevalence study of CPE faecal carriers in LTCHs in Spain. OXA-48, the most prevalent carbapenemase, showed a complex dissemination pattern with clonal and polyclonal bacterial populations.

Guía de práctica clínica sobre terapia intravenosa con dispositivos no permanentes en adultos / Clinical practice guideline on intravenous therapy with temporary devices in adults

El objetivo principal de la guía es proporcionar a los profesionales sanitarios una herramienta que les permita tomar decisiones basadas en evidencia sobre aspectos de la atención al paciente adulto con indicación de terapia intravenosa con dispositivos no permanentes. Además, se señalan los objetivos secundarios siguientes: aumentar la calidad de las intervenciones, evitar complicaciones relacionadas con la terapia intravenosa y reducir la variabilidad existente entre los profesionales sanitarios.

The guideline includes recommendations for taking care of adult patients with intravenous therapy who are at primary care centres, hospitals and homes.

Intervención en el estreñimiento en Atención Primaria de Salud / Treatment of constipation in Primary Health Care

Objetivo: determinar si una intervención de educación sanitaria(centrada en el ejercicio, la dieta, uso de laxantes, hábitos defecatorios,etc.) disminuiría la prevalencia de estreñimiento crónico primario,así como su intensidad.Material y método: estudio de intervención tipo antes-despuéssobre individuos adultos del ABS Río de Janeiro 8B que padecíanestreñimiento crónico primario. Se eligieron 20 individuos a travésde un muestreo consecutivo.La variable independiente era la intervención educativa y como variablesdependientes se encontraban tanto las manifestaciones dedependencia del estreñimiento como sus factores relacionados.Además se estudiaron las variables edad y sexo. Como fuente dedatos se utilizó la encuesta directa y la Historia Clínica de AtenciónPrimaria. Se computaron índices de estadística descriptiva (media,porcentajes, etc.) a través de la aplicación informática SPSS.Resultados: el 80% de los individuos con estreñimiento eran mujeres,la media de edad era de 57 años. Todos los individuos despuésde la intervención consiguieron evacuar cada día o cada dosdías sin esfuerzo. La consistencia y el sangrado son otras de lasmanifestaciones de dependencia que mejoraron más, aunque elresto (dolor, distensión, flatulencias y ruidos intestinales) tambiénmejoraron. La media de fibra consumida al día se incrementó en10 gramos y la ingesta de agua en 6 vasos. Todos realizaron ejerciciofísico moderado. El 46,6% empezó a adoptar una postura adecuadaen el wc, el 80% estableció un horario, pero un 20% continuabademorando la hora de defecar.Conclusiones: los resultados permiten demostrar la eficacia de laeducación sanitaria en la disminución de la prevalencia del estreñimento.Después de la intervención todos los individuos comunicaronmejoría en todas las manifestaciones de dependencia (fundamentalmenteen el ritmo deposicional, en el dolor al defecar y enel esfuerzo al defecar) y en los factores relacionados con el estreñimiento(especialmente en el aumento en de fibra y agua, la intensidaddel ejercicio, la adopción de postura correcta y en el establecimientode un horariolo para defecar)

Objectives: to determine whether a health education intervention(based on exercise, dieting, the use of laxatives, bowel movementshabits, etc.) would decrease the prevalence and intensity of primarychronic constipation.Material and methods: before and after interventional study onadult individuals in the Río de Janeiro 8B health care district withprimary chronic constipation. Twenty individuals were selectedthrough consecutive sampling.The independent variable was an educational intervention and thedependent variables were the dependence manifestations of constipationas well as other related factors. Other variables such asage and gender were also studied. A direct survey and the medicalhistory were used as data sources for the retrieval of information.Descriptive statistics indexes were computed (mean value, percentages,etc.) using the SPSS software.Results: 80% of the individuals with constipation were women,mean age was 57 years. All the individuals were able to have abowel movement each day or every other day without much effortafter the intervention. The consistency and bleeding were otherdependence manifestations that improved the most, even thoughthe rest (pain, distension, flatulence and intestinal sounds) improvedalso. The mean amount of fibre consumed per day increasedby 10 grams while the water intake increased by 6 glasses.All subjects performed moderate exercise. 56,6% started to adoptproper body positioning in the WC, 80% established a schedule,but 20% continued to delay the defecation time.Conclusions: the results demonstrate that health education hasbeen proven to be effective to decrease the prevalence of constipation.After the intervention, all the subjects reported improvementin all the dependence manifestations (basically in the rhythmto defecate, the pain to defecate, and the effort to defecate) andimprovement in the constipation-related factors (especially in increasedintake of fibre and water, the intensity of exercise, theadoption of the right posture and the establishment of certainhours to have the bowel movements)