[Quality in medicine as a deontological requirement]. / La calidad en medicina como obligación deontológica.

Medical practice has two main dimensions, one scientific and the other human, and in both, the commitment of the doctor is essential. Medical deontology, as a branch of ethics that deals with the duties and obligations of doctors, embodies in the codes of deontology the ethical principles and standards of mandatory compliance. From this point, medical practice should guarantee that patients receive an quality medical care, and to be treated with dignity and respect. In December 2022, the General Council of Official Medical Associations of Spain published a new version of the Spanish Code of Medical Ethics that aims, among other purposes, to standardize medical care of scientific and human quality. Medical practice supported by scientifically-based medicine, lex artis medica, patient safety, professional responsibility, honesty and integrity are some of the aspects that in this updated document of medical ethics frame and define the work of the doctor for a performance of medicine with quality.

La calidad en medicina como obligación deontológica / Quality in medicine as a deontological requirement

La práctica médica tiene dos dimensiones fundamentales una la científica, y otra la humana, y en ambas es esencial el compromiso del médico. La deontología médica, como rama de la ética que se ocupa de los deberes y obligaciones de los médicos, plasma en los códigos de deontología los principios y están dares éticos de obligado cumplimiento, a fin de que la práctica médica pueda garantizar que los pacientes reciban una atención médica de calidad, y que se les trate con dignidad y respeto. En diciembre del año 2022 el Consejo General de Colegios Oficiales de Médicos de España publicó una nueva versión del Código de Deontología Médica español que pretende, entre otros fines, normativizar una asistencia médica de calidad científica y humana. Práctica médica sustentada en medicina con base científica, lex artis médica, seguridad del paciente, responsabilidad profesional, honestidad e integridad son algunos de los aspectos que en este documento actualizado de deontología médica enmarcan y define el quehacer del médico para un desempeño de medicina con calidad (AU)

Medical practice has two main dimensions, one scientific and the other human, and in both, the com mitment of the doctor is essential. Medical deontology, as a branch of ethics that deals with the duties and obligations of doctors, embodies in the codes of deontology the ethical principles and standards of mandatory compliance. From this point, medical practice should guarantee that patients receive an quality medical care, and to be treated with dignity and respect. In December 2022, the General Council of Official Medical Associations of Spain published a new version of the Spanish Code of Medical Ethics that aims, among other purposes, to standardize medical care of scientific and human quality. Medical practice sup ported by scientifically-based medicine, lex artis médica, patient safety, professional responsibility, honesty and integrity are some of the aspects that in this updated document of medical ethics frame and define the work of the doctor for a performance of medicine with quality (AU)

Leadership, management, quality, and innovation in organ donation: 2019 Kunming recommendations for One Belt & One Road countries.

The findings and recommendations of the 2019 consensus conference in organ donation, held in Kunming, China, are here reported. The main objective of the conference was to gather relevant information from experts involved in the field. The data and opinions provided allowed to propose a series of recommendations for "One Belt & One Road Countries" on how to achieve self-sufficiency in organ donation. Leadership in organ donation should be results-oriented and goal-driven based on the principles of excellence, empowerment, and engagement, providing the means, resources, and strategies necessary to reach the goal in earnest. Management includes good governance and transparency of a national registry of patients in the waiting list, donors, transplants, transplant teams, quality, and safety programs with continuous educational training of health care professionals. Mandatory monitoring, auditing and evaluation of quality must be incorporated into donation practices as relevant points in innovation, as well as the adoption of already established and novel processes and technologies. Achievement of self-sufficiency in organ donation is a crucial step to fight against transplant tourism and to prevent organ trafficking. Based on recommendations arising from the conference, each country could review and develop individualized action plans adjusted to its own circumstances and reality.

Leadership, management, quality, and innovation in organ donation: 2019 Kunming recommendations for One Belt & One Road countries

ABSTRACT The findings and recommendations of the 2019 consensus conference in organ donation, held in Kunming, China, are here reported. The main objective of the conference was to gather relevant information from experts involved in the field. The data and opinions provided allowed to propose a series of recommendations for "One Belt & One Road Countries" on how to achieve self-sufficiency in organ donation. Leadership in organ donation should be results-oriented and goal-driven based on the principles of excellence, empowerment, and engagement, providing the means, resources, and strategies necessary to reach the goal in earnest. Management includes good governance and transparency of a national registry of patients in the waiting list, donors, transplants, transplant teams, quality, and safety programs with continuous educational training of health care professionals. Mandatory monitoring, auditing and evaluation of quality must be incorporated into donation practices as relevant points in innovation, as well as the adoption of already established and novel processes and technologies. Achievement of self-sufficiency in organ donation is a crucial step to fight against transplant tourism and to prevent organ trafficking. Based on recommendations arising from the conference, each country could review and develop individualized action plans adjusted to its own circumstances and reality.

Consenso internacional sobre la monitorización de la presión tisular cerebral de oxígeno en pacientes neurocríticos / International consensus on the monitoring of cerebral oxygen tissue pressure in neurocritical patients

La monitorización continua de la oxigenación cerebral y su aplicación al manejo del paciente neurológico grave es uno de los grandes retos actuales de la medicina crítica. Aunque han sido descritas diversas técnicas para la monitorización de la oxigenación cerebral, la monitorización tisular cerebral de oxígeno proporciona una relevante información sobre los niveles de oxígeno a nivel del tejido cerebral. Su desarrollo se ha asociado a la necesidad de responder no solamente aspectos técnicos sobre la misma, sino también al significado de la alteración de los valores de la oxigenación cerebral en el paciente neurocrítico. El documento de consenso da respuesta a diversas cuestiones relativas a la monitorización de la oxigenación cerebral mediante sensor de presión tisular cerebral de oxígeno. Para ello se elaboró un panel de preguntas y se realizó una revisión de la literatura médica, y evaluando la calidad de la evidencia y el nivel de recomendación mediante la metodología GRADE

Continuous monitoring of cerebral oxygenation and its application to the management of the severe neurological patient is a challenge for the management of patients with acute critical brain damage. Although several techniques have been described for monitoring brain, brain tissue oxygen monitoring provides relevant information about oxygen levels of brain tissue. However, the development of this technique has been associated with the need to answer not only some technical aspects of it as well as the meaning of the changes of the cerebral oxygenation in the neurocritical patient. The consensus document responds to various questions related to the monitoring of cerebral oxygenation by means of a cerebral oxygen tissue pressure sensor. For this purpose, a list of questions was prepared and a reviewed of the medical literature was made. The quality of the evidence and the degree of recommendation was evaluated using the GRADE methodology

International consensus on the monitoring of cerebral oxygen tissue pressure in neurocritical patients. / Consenso internacional sobre la monitorización de la presión tisular cerebral de oxígeno en pacientes neurocríticos.

Continuous monitoring of cerebral oxygenation and its application to the management of the severe neurological patient is a challenge for the management of patients with acute critical brain damage. Although several techniques have been described for monitoring brain, brain tissue oxygen monitoring provides relevant information about oxygen levels of brain tissue. However, the development of this technique has been associated with the need to answer not only some technical aspects of it as well as the meaning of the changes of the cerebral oxygenation in the neurocritical patient. The consensus document responds to various questions related to the monitoring of cerebral oxygenation by means of a cerebral oxygen tissue pressure sensor. For this purpose, a list of questions was prepared and a reviewed of the medical literature was made. The quality of the evidence and the degree of recommendation was evaluated using the GRADE methodology.

Efficacy and safety of caspofungin in critically ill patients. ProCAS Study

Introducción. Caspofungina es una equinocandina con eficacia probada en candidiasis invasiva (CI) y aspergilosis invasiva (AI). ProCAS es un estudio patrocinado por el Grupo de Trabajo de Enfermedades Infecciosas de la Sociedad Española de Medicina Intensiva Critica Y Unidades Coronarias (Semicyuc), que trata de analizar su efectividad y seguridad en condiciones de práctica clínica habitual en el paciente grave ingresado en UCI. Material y métodos. Estudio observacional, prospectivo y multicéntrico que tiene como objetivo estimar la efectividad clínica y la seguridad del acetato de caspofungina en el tratamiento de CI y de AI en pacientes críticos refractarios o intolerantes al tratamiento antifúngico convencional. La valoración de la efectividad tanto clínica como la microbiológica se realizó al final del tratamiento con caspofungina. Resultados. Se incluyeron 98 pacientes; 62 CI probadas, 25 CI probables y 11 AI probables, procedentes de 24 centros, durante los años 2005 y 2006. El tratamiento con caspofungina se realizó en monoterapia en el 89.8% de los casos y como primera línea en el 54.1%. La respuesta clínica favorable obtenida para CI, CI probable y AI probable fue de 91,9%, 84% y 81.8%, respectivamente. La respuesta microbiológica fue favorable en el 74,6%, 68% y 54.6%, para los casos de CI probada, CI probable y AI probable, respectivamente. No se objetivaron efectos adversos graves. Conclusiones. En condiciones de práctica clínica habitual, caspofungina es eficaz y segura para el tratamiento de infecciones fúngicas invasoras (CI/AI). El perfil de eficacia y seguridad fue similar al observado en los ensayos clínicos publicados(AU)

Introduction. Caspofungin is an echinocandin with proven efficacy in invasive candidiasis (IC) and invasive aspergillosis (IA). ProCAS is a study sponsored by the Working Group of the Infectious Diseases of the Spanish Society of Intensive Care Medicine, which analyzes the effectiveness and safety of caspofungin in routine clinical practice conditions in the critically ill. Methods. A prospective, multicenter, observational study designed to estimate the clinical effectiveness and safety of caspofungin acetate in the treatment of IC and IA in patients refractory to or intolerant of conventional antifungal therapy. The assessment of effectiveness both clinic and the microbiological was carried out at the end of the treatment with caspofungin. Results. We included 98 patients, 62 IC proven, 25 probable and 11 IA probable, from 24 centers during 2005 and 2006. Treatment with caspofungin monotherapy was performed in 89.8% of cases and as first line therapy in 54.1%. The favorable clinical response obtained for IC, probable IC, and probable IA was 91.9, 84, and 81.8%, respectively. The microbiological response was favorable in 74.6, 68, and 54.6% for proven cases of IC, probable IC, and probable IA, respectively. No serious adverse effects were observed. Conclusions. In routine clinical practice conditions, caspofungin is effective and safe for the treatment of invasive fungal infections (IC/IA). The efficacy and safety profile was similar to that observed in published clinical trials(AU)

Role of S100B protein in urine and serum as an early predictor of mortality after severe traumatic brain injury in adults.

S100B is a calcium-binding protein released into the blood from astroglial cells due to brain injury. Some authors have described a correlation between S100B serum concentration and severity of brain damage. There is not much information about the accuracy of urinary S100B for predicting outcome after severe traumatic brain injury (TBI). 55 patients with severe TBI were included in the study. Blood and urine samples were drawn to determine S100B levels on admission and on the subsequent 24, 48, 72 and 96 h. S100B concentrations (serum and urine) were significantly higher in patients who were dead a month after the accident compared to survivors. ROC-analysis showed that S100B at 24h post-severe TBI is a useful tool for predicting mortality (serum: AUC 0.958, urine: AUC 0.778). The best cut-offs for S100B were 0.461 µg/L and 0.025 µg/L (serum and urine respectively), with a sensitivity of 90% for both measurements and a specificity of 88.4% (serum) and 62.8% (urine). We can state that the determination of S100B levels both in urine and serum acts as a sensitive and an effective biomarker for the early prediction of mortality after severe TBI.

Role of early cell-free DNA levels decrease as a predictive marker of fatal outcome after severe traumatic brain injury.

INTRODUCTION: Circulating cell-free DNA levels are increased after trauma injury. This increase is higher since the first hours after trauma and may be related with primary outcome. A sensitive and reliable biomarker for patients at higher risk is needed to identify these patients to initiate early intervention. In this way, circulating DNA may be a possible biological marker after severe TBI. MATERIALS AND METHODS: We investigated DNA plasma concentrations after severe traumatic brain injury and during the next 96 h in the Intensive Care Unit (ICU) by real time PCR. 65 patients suffering severe TBI were included in the study. RESULTS: Cell-free DNA levels were considerably higher in patients samples compared with voluntary control ones. After the following four days we observed a 51% decrease during the first 24h and a 71% fall from 48 h. TBI population was stratified for the primary outcome (survivors/non-survivor) and DNA levels decrease ratio was calculated for the first 48 h. A higher decrease in the survivors from 0 h to 24h compared with the non-survivors was found. A cut-off point of 1.95 ratio was established for the detection of the highest proportions of patients after the TBI that will not survive after the injury with a sensitivity of 70% and specificity of 66%. CONCLUSIONS: In summary we showed that severe TBI is associated with elevated cf-DNA levels and we propose that cf-DNA decrease during the first 24h may predict patient outcome.

Efficacy and safety of caspofungin in critically ill patients. ProCAS Study.

INTRODUCTION: Caspofungin is an echinocandin with proven efficacy in invasive candidiasis (IC) and invasive aspergillosis (IA). ProCAS is a study sponsored by the Working Group of the Infectious Diseases of the Spanish Society of Intensive Care Medicine, which analyzes the effectiveness and safety of caspofungin in routine clinical practice conditions in the critically ill. METHODS: A prospective, multicenter, observational study designed to estimate the clinical effectiveness and safety of caspofungin acetate in the treatment of IC and IA in patients refractory to or intolerant of conventional antifungal therapy. The assessment of effectiveness both clinic and the microbiological was carried out at the end of the treatment with caspofungin. RESULTS: We included 98 patients, 62 IC proven, 25 probable and 11 IA probable, from 24 centers during 2005 and 2006. Treatment with caspofungin monotherapy was performed in 89.8% of cases and as first line therapy in 54.1%. The favorable clinical response obtained for IC, probable IC, and probable IA was 91.9, 84, and 81.8%, respectively. The microbiological response was favorable in 74.6, 68, and 54.6% for proven cases of IC, probable IC, and probable IA, respectively. No serious adverse effects were observed. CONCLUSIONS: In routine clinical practice conditions, caspofungin is effective and safe for the treatment of invasive fungal infections (IC/IA). The efficacy and safety profile was similar to that observed in published clinical trials.

The Infrascanner, a handheld device for screening in situ for the presence of brain haematomas.

PURPOSE: Early identification and treatment of intracranial haematomas in patients sustaining traumatic brain injury is fundamental to successful treatment. This pilot study evaluates the Infrascanner as a handheld medical screening tool for detection, in situ, of brain haematomas in patients with head injury. METHODS: This study included 35 TBI patients aged 17-76 (M = 47.6), admitted to the neurosurgical intensive care unit and observation unit of a University Hospital in a Level 1 trauma centre. The Infrascanner NIRS device uses near infrared light measurements to calculate optical density in brain regions. RESULTS: Results show Infrascanner sensitivity at 89.5% and specificity at 81.2%. PPV was 85% and NPV 86.7%. The device detected 90% of extra-axial, 88.9% of intra-axial and 93.3% of non-surgical haematomas (less than 25 mL). PPV for this classification was 82.3%; 87.5% sensitivity was found when the Infrascanner exam was performed within 12 hours post-trauma, whereas after 12 hours post-trauma, exams had 90.1% sensitivity. CONCLUSIONS: This study demonstrates that the Infrascanner is useful in initial examinations and screenings of patients with head injury as an adjunct to a CT scan or when it is not available and may allow earlier treatment and reduce secondary injury caused by present and delayed haematomas.

The hemodynamics of cognitive control: the level of concentration of oxygenated hemoglobin in the superior prefrontal cortex varies as a function of performance in a modified Stroop task.

The purpose of this study was to establish the relationship between the hemodynamic response of prefrontal cortex (PFC) and individual differences in cognitive control, as measured by a color-word interference task. Twenty-five healthy volunteers were observed through functional near infrared spectroscopy (fNIRS) while performing a modified Stroop paradigm. Mean concentration levels of oxygenated hemoglobin (oxy-Hb) were correlated with behavioral performance in the conflict task. Those with shorter reaction times had higher levels of oxy-Hb concentration in superior dorsolateral PFC. Our results are the first to show a positive correlation between behavioral performance and oxy-Hb levels in superior dorsolateral PFC in a cognitive conflict task. These results suggest that the availability of oxygen in the superior PFC, possibly linked to an increase in metabolism, may be related to attention level and effectiveness of cognitive control.

Empiric broad-spectrum antibiotic therapy of nosocomial pneumonia in the intensive care unit: a prospective observational study.

INTRODUCTION: Antibiotic de-escalation, which consists of the initial institution of empiric broad-spectrum antibiotics followed by antibiotic streamlining driven by microbiological documentation, is thought to provide maximum benefit for the individual patient, while reducing the selection pressure for resistance. METHODS: To assess a carbapenem-based de-escalating strategy in nosocomial pneumonia (NP), a prospective observational study was conducted in critically ill patients with NP treated empirically with imipenem +/- aminoglycoside/glycopeptide in 24 intensive care units of Spanish general hospitals. Overall, 244 patients were assessable (91% with late-onset NP). The primary outcome was therapeutic success 7-9 days post therapy. RESULTS: Microbial identification--based on cultures of tracheal aspirates in 82% of patients, cultures of protected specimen brush in 33%, and cultures of bronchoalveolar lavage in 4%--was only available for 131 (54%) patients. Initial antibiotics were inadequate for 23 (9%) patients. Of the remaining patients, antibiotics were streamlined in 56 (23%) patients and remained unchanged in 14 (6%) patients based on microbiology data, in 38 (16%) patients despite microbiology data favouring de-escalation, and in 113 (46%) patients due to unknown aetiology. Overall, de-escalation was implemented in only 23% of patients with potentially multiresistant pathogens, compared with 68% of patients with the remaining pathogens (P < 0.001). Response rates were 53% for patients continuously treated with imipenem-based regimens and 50% for the de-escalated patients. Higher Acute Physiology, Age, and Chronic Health Evaluation II scores were associated with greater mortality, whereas adequate empiric antibiotic therapy protected against fatal outcomes. No increase of superinfection rates caused by emerging pathogens was observed. The costs associated with de-escalation were mainly dependent on the duration of hospitalization. CONCLUSION: This study mainly highlights the current practice of a specific algorithm of de-escalation solely based on the available microbiological data, and highlights the barriers to using it more widely. In this setting, de-escalation was less likely to occur in the presence of potentially multiresistant pathogens. Prior antibiotic administration and the low use of bronchoscopic techniques may have influenced negatively the implementation of de-escalation. Optimization of de-escalation strategies for NP should rely on a correct choice of empiric antibiotics, on appropriate microbiological investigations, and on a balanced interpretation of microbiological and clinical data.

The role of citicholine in neuropsychological training after traumatic brain injury.

Objective: To report new strategies in the treatment of persistent memory deficits following traumatic brain injury (TBI) using a combination of pharmacology and neuropsychological training. Study design: Two studies were carried out. The first study measured the regional cerebral blood flow (rCBF) of seven Patients with TBI with very severe memory deficits, once while resting and once one hour after the administration of citicholine (CDPc). In the second study, two groups of five patients of the same characteristics underwent an ecological neuropsychological memory rehabilitation program; during which time, one group was administered a placebo (Group A), and the other received CDPc (1~g/d v.o.) (Group B). Results: The results of Experiment 1 showed a hypoperfusion of the inferior left temporal cerebral blood flow during rest state while an induced normalization was observed after administration of the drug. Results of Experiment 2 showed no improvements in Group A's neuropsychological functions, while memory, learning processes and verbal fluency of Group B improved significantly after treatment. Conclusions: CDP-choline seems to be a drug with special affinity for cerebral areas associated with memory acting just where needed, normalizing blood flow in the hypoperfused left temporo-basal region, and making neuropsychological training effective. In general, data suggests that cognitive rehabilitation would follow the principle of first restoring and maintaining cerebral blood flow in the lesional site and then exercising function. In this study on memory rehabilitation, memory recuperation was made possible by first normalizing blood flow at the lesional site and at the same time applying neuropsychological training.