[Recommendations for the care of patients with community-acquired pneumonia in the Emergency Department]. / Recomendaciones para la atención del paciente con neumonía adquirida en la comunidad en los Servicios de Urgencias.

The incidence of community-acquired pneumonia (CAP) ranges from 2-15 cases / 1,000 inhabitants / year, being higher in those older than 65 years and in patients with high co-morbidity. Around 75% of all CAP diagnosed are treated in the Emergency Department (ED). The CAP represents the main cause for sepsis and septic shock in ED, and the most frequent cause of death and admission to the Intensive Care Unit (ICU) due to infectious disease. Overall mortality is 10-14% according to age and associated risk factors. Forty to 60% of CAP will require hospital admission, including observation units (with very variable ranges from 22-65% according to centers, seasonal of the year and patients´ characteristics). Between the admissions, 2-10% will be in the ICU. All of previously mentioned reflects the importance of the CAP in the ED, as well as the "impact of the emergency care on the patient with CAP", as it is the establishment where the initial, but key decisions, are made and could condition the outcome of the illness. It is known the great variability among physicians in the diagnostic and therapeutic management of CAP, which is one of the reasons that explains the great differences in the admission rates, achievement of the microbiological diagnosis, request for complementary studies, the choice of antimicrobial treatment, or the diversity of applied care. In this sense, the implementation of clinical practice guidelines with the use of the severity scores and the new tools available, such as biomarkers, can improve patient care with CAP in ED. Therefore, a multidisciplinary group of emergency professionals and specialists involved in the care process of CAP has designed a guideline with several recommendations for decisions-making during the key moments in patients with CAP attended in the ED.

Abordaje terapéutico del insomnio / Therapeutic approach to insomnia

El insomnio es la incapacidad para conciliar o mantener el sueño o la sensación de no haber tenido un sueño reparador que ocasiona disfunción diurna. Repercute de forma importante en la salud y la calidad de vida de quien lo presenta. Pese a ello, hasta el 10% de los pacientes insomnes no reciben el tratamiento adecuado. Debe realizarse un abordaje integral tratando las causas o desencadenantes y sus síntomas y valorando su repercusión en el paciente. El tratamiento debe basarse en estrategias de modificación de conductas y cambios en el estilo de vida a las que se asociará, cuando se considere necesario, tratamiento farmacológico. Los principales hipnóticos son las benzodiacepinas y los fármacos Z o hipnóticos no benzodiacepínicos, sin que se hayan encontrado evidencias de diferencias clínicamente significativas sobre la utilización de unas u otros. Ambos grupos terapéuticos son eficaces en el tratamiento del insomnio a corto plazo pero no se dispone de evidencia sobre su eficacia a largo plazo en este cuadro (AU)

Insomnia is the inability to reconcile or maintain sleep or the feeling of not having a good night's sleep, resulting in daytime dysfunction. It affects health and the quality of life of patients who suffer from it. However, up to 10% of insomniac patients do not receive an adequate treatment. Insomnia requires an integrated approach, treating the causes or triggers and symptoms, and assessing their impact on the patient. Treatment must be based on strategies of changing behaviour and changes in lifestyle that are associated, and when deemed necessary, pharmacological treatment. The main hypnotics are benzodiazepines and Z drugs or non-benzodiazepine hypnotics, on not finding any evidence of clinically significant differences between the use of one or the other. Both therapeutic groups are effective in the treatment of insomnia in the short term, but there is no evidence on their long-term effectiveness (AU)

[Therapeutic approach to insomnia]. / Abordaje terapéutico del insomnio.

Insomnia is the inability to reconcile or maintain sleep or the feeling of not having a good night's sleep, resulting in daytime dysfunction. It affects health and the quality of life of patients who suffer from it. However, up to 10% of insomniac patients do not receive an adequate treatment. Insomnia requires an integrated approach, treating the causes or triggers and symptoms, and assessing their impact on the patient. Treatment must be based on strategies of changing behaviour and changes in lifestyle that are associated, and when deemed necessary, pharmacological treatment. The main hypnotics are benzodiazepines and Z drugs or non-benzodiazepine hypnotics, on not finding any evidence of clinically significant differences between the use of one or the other. Both therapeutic groups are effective in the treatment of insomnia in the short term, but there is no evidence on their long-term effectiveness.

Valoración de la repercusión del tabaco en la función pulmonar según el sexo / No disponible

Objetivo: Valorar la posible existencia de diferencias, en función del sexo, de la repercusión del tabaco sobre la función pulmonar. Pacientes y método: Se realizó un estudio descriptivo transversal (primer trimestre 2010), en tres ZBS de Toledo. Los participantes fueron fumadores mayores de 18 años (se excluyeron los pacientes con patología oncológica pulmonar, fibrosis quística, enfermedad pulmonar profesional, disfunciones cognitivas, contraindicaciones para poder realizar una espirometría, y no ser hispano- hablantes). Tras contactar telefónicamente, se citó a los pacientes para realizar una espirometría aprovechando dicha situación para realizar el consejo antitabaco. Si padecían un proceso respiratorio agudo se retrasó la cita diez días tras resolución del cuadro. Se recogió: edad, sexo, edad de inicio de hábito tabáquico, índice tabáquico (IT), función pulmonar- espirometría. Resultados: N= 153. Edad media 49±13,59 años. 61,4% hombres. Edad media inicio del consumo de tabaco 18,18±5,95 (inferior en hombres sin diferencias signifi cativas). Índice tabáquico: mediana 25 (RI 36-15), con diferencias signifi cativas entre sexos (hombres 28 vs mujeres 23; z=-2,107 p<0,05). Los valores medios de los datos espirométricos fueron: CVF: 86,41 (DE 17,44); FEV1: 88,94 (DE 18,09); FEV1/CVF: 85,01 (DE 13,64); MEF25-75: 87,94 (DE 32,42). Existían diferencias signifi cativas entre sexos en los valores medios de CVF, FEV1 y MEF25-75. Un 39,1% tenía un FEV1/CVF < 80 y el 16,99% valores de MEF25-75 <60, sin diferencias por sexos en estos grupos. En hombres, el IT se correlaciona signifi cativamente con CVF (rho: -0,309; p<0,001), FEV1 (rho: -0,320; p<0,001) y MEF25-75 (rho: -0,211; p<0,05), no encontrándose correlaciones significativas entre estos parámetros y el IT en mujeres. Se creó un modelo de regresión lineal entre IT y FEV1 para cada sexo obteniéndose una B= -0,035 en mujeres y una B=-0.182 en varones. Conclusiones: En nuestra muestra, la afectación que produce el tabaco parece ser diferente entre hombres y mujeres, con mayor repercusión en los hombres. Sería necesario realizar nuevos estudios para contrastar estos resultados (AU)

No disponible

Hemodynamic changes during reperfusion of the graft in an animal model of liver xenotransplantation.

UNLABELLED: Our goal was to determine the hemodynamic changes that are witnessed during the initial minutes of reperfusion of the graft in liver xenotransplantation from pig to baboon. METHOD: We studied a group of 12 baboons undergoing transplantation of a pig liver via the classic technique with arterial anastomosis to the aorta. The anesthesia technique was similar to that used in humans. Hemodynamic monitoring, due to the size of the recipient, consisted of heart rate (HR), mean arterial pressure (MAP), and central venous pressure (CVP) recorded at the beginning and end of each of the three phases: preanhepatic (A1, A2), anhepatic (B1, B2), and neohepatic (C1 and C2). We aimed to maintain the following values by means of crystalloids, colloids, and blood derivates: HR >50 beats/minute; MAP >60 mm Hg; and CVP >10 mm Hg. RESULTS: Both HR and CVP remained unchanged throughout the procedure. MAP droped briefly after vascular clamping (B1) but not on reperfusion (C1). CONCLUSION: In cirrhotic patients there is an autonomic dysfunction, demonstrated as cardiovascular instability at times like the clamping of major vessels and reperfusion of the graft. On the other hand, the intact baboon has an intact nervous system. After vascular clamping, the sharp decrease in venous return lead to an adequate vasopressor response. Likewise, the extreme vasodilatation involved with reperfusion managed to maintain MAP above 70 mm Hg.

Hemodynamic assessment during auxiliary heterotopic liver transplantation with portal vein arterialization in a Swine model: preliminary report of 10 transplants.

UNLABELLED: Portal vein arterialization (PVA) is a technical variation of auxiliary heterotopic liver transplantation (AHLT) that is rarely studied but that simplifies the AHLT surgical technique because it does not act on the portal area. The objective of this study was to analyze the hemodynamic consequences of this auxiliary transplant in an experimental model. MATERIALS AND METHODS: Ten AHLT-PVA were analyzed in a pig model. A PiCCO (Pulsion) monitor was used for the hemodynamic study of the recipient. The following were measured: cardiac index, (CI), systemic vascular resistance index, (SVRI), mean arterial pressure (MAP), global end-diastolic volume, central venous pressure, and intrathoracic blood volume. The measurements were taken at four times during transplant: at baseline, after inferior vena cava clamping, after graft reperfusion, and at closure. RESULTS: After graft reperfusion there was a reduction in SVRI (968 +/- 168.03 vs 1686.25 +/- 290.66; P < .05) and in MAP, and there was an increase in CI. At the end of the transplant MAP and SVRI recovered (1254.2 +/- 225.79 vs 968 +/- 168.03; P < .05) but CI remained slightly high. The end-diastolic volume showed greater variation than central venous pressure, although this was only statistically significant at the inferior vena cava clamping phase (244.75 +/- 52.05 vs 333.37 +/- 170.13; P < .05). DISCUSSION: Heterotopic liver transplantation with portal arterialization is well-tolerated hemodynamically. Graft reperfusion decreases SVRI and increases CI to compensate for this. This behavior, which in healthy recipients like ours is not a problem, could imply a contraindication in patients with a prior hyperdynamic state.

Doppler ultrasonographic and scintigraphic assessment of an auxiliary heterotopic liver transplantation with portal vein arterialization in pigs.

OBJECTIVE: Our aim was to evaluate liver graft integrity and function using scintigraphy and ultrasonography in a porcine model of auxiliary heterotopic liver transplantation with portal vein arterialization (AHLT-PVA). MATERIALS AND METHODS: Using Doppler ultrasonography we evaluated eight AHLT-PVA by parenchymal echogenicity, portal and arterial anatomy, and portal and biliary system flow. Two types of scintigraphy were performed: microaggregated human albumin colloid scintigraphy and diisopropyl iminodiacetic acid (DISIDA) scintigraphy, both labeled with 99mTc. RESULTS: The animals were distributed into two groups. The first group consisted of three animals with clinical suspicion of graft dysfunction, in which the ultrasonographic study revealed areas of parenchymal destructuring. In the scintigraphic study, heterogenous uptake was observed; there was no uptake in one animal. Necropsy of these three animals revealed areas of graft necrosis. The second group consisted of five animals with good clinical evolutions, in which the ultrasonographic study showed portal dilation, portal flow with arterial spiculations, and homogenous echogenicity of the hepatic parenchyma. The scintigraphic study revealed homogenous uptake by the graft and an elimination speed of the hepatobiliary agent similar to that of the native liver. CONCLUSIONS: An heterogenous echostructure of the graft provided a sign of poor prognosis indicating necrosis in the same way as heterogenous uptake or nonuptake of radioisotope upon scintigraphy. Scintigraphy is a good method to evaluate biliary function and bile elimination. In an AHLT-PVA, the main ultrasound findings derived from arterialization were dilation of the portal system and portal flow with arterial spiculations.

Investigación en atención primaria: 1994-2003 / Research in primary care: 1994-2003

Objetivos. Conocer las características de los artículos originales publicados en la revista Atención Primaria en los últimos 10 años. Diseño. Estudio bibliométrico. Emplazamiento. Atención primaria de salud. Participantes. Artículos originales publicados en Atención Primaria entre 1994 y 2003. Mediciones principales. La categoría profesional de los autores, si se trataba de un estudio multidisciplinario y si era multicéntrico, la comunidad autónoma de procedencia, el tema, el tipo de estudio y si constaba alguna beca o ayuda. Resultados. Se han revisado 1.229 artículos. En el 40,0% figura la autoría de un médico de familia. El 31,4% se puede considerar multidisciplinario y el 20,5% multicéntrico. Las comunidades valenciana, madrileña, andaluza y catalana acaparan más del 60% del volumen de publicaciones. El tema más común es el relacionado con la prestación y organización de los servicios sanitarios (40,5%). Sólo un 4,3% de los diseños es experimental. En el 16,2% de los artículos consta alguna beca o ayuda. Conclusiones. Aunque la situación respecto a años anteriores no ha variado demasiado, algunos hallazgos positivos, como la emergencia de grupos de investigadores, la presencia cada vez mayor de estudios multicéntricos y multidisciplinarios, el mayor acceso a fuentes de financiación, etc., sugieren que estamos en un proceso de mejora de la calidad investigadora en atención primaria

Objectives. To analyse the characteristics of the original articles published in the journal Atención Primaria (Primary Care) during the last 10 years. Design. Literature study. Setting. Primary health care. Participants. Original articles published in Atención Primaria between 1994 and 2003. Main measurements. The professional category of the authors, whether it was a multidisciplinary or multicentred study, the autonomous community of origin, the topic, the type of study, and if it had a grant or financial assistance. Results. 1229 articles have been reviewed. In 40.0% of them a family doctor is included in the authorship. 31.4% can be considered multidisciplinary and 20.5% multicentred. The Communities of Valencia, Madrid, Andalusia, and Catalonia took up 60% of the volume of publications. The most common topic is the provision and organisation of the health services (40.5%). Only 4.3% of the designs are experimental. A grant or financial aid is stated in 16.2% of the articles. Conclusions. Although the situation as regards the previous years has not varied too much, some positive findings, such as the emergence of research groups, increasing presence of multicentre and multidisciplinary studies, better access to sources of finance, etc, suggest that we are in a process of improving the quality of research in primary care

Description of a new auxiliary heterotopic partial liver transplantation technique with portal vein arteriolization of applicability in heterotopic liver xenotransplantation.

OBJECTIVE: The aim of this study was to describe a new model of auxiliary heterotopic partial liver transplantation with portal vein arterialization. MATERIALS AND METHODS: Three standard hepatectomies were performed in pigs. The left lateral lobe was surgically resected and portal vein arteriolization constructed by an end-to-side "Y" anastomoses between the distal to the celiac axis aorta and the portal vein. RESULTS: The graft was placed in the left iliaca fossa using anastomoses of the donor infrahepatic inferior cava vein end-to-side to the host infrarenal inferior vein and the donor aortic stump with portal vein arteriolization end-to-side to the left iliac artery. After graft reperfusion, the 3 recipients showed intraoperative hypotension, which was treated with fluid administration and vasoactive drugs. At the end of the operation, the graft displayed normal arterial blood flow and good venous drainage. The donor liver graft appeared more red than the host liver, which was due to the increased arterial blood flow. One pig of 3 died at 24 hours after surgery, probably due to hypothermia. However, the other 2 pigs survived the procedure and remained stable. Echographic monitoring showed intrahepatic arterial expansion, which may be the result of high blood pressure due to the arteriolization procedure. CONCLUSIONS: We have developed a novel and easy to perform technique that diminishes the number of anastomoses and does not involve vessels from other organs.