Eficacia y seguridad de dos emulsiones lipídicas de nutrición parenteral en pacientes críticos posquirúrgicos: Clinoleic(R) frente a SMOFlipid(R) / Effectiveness and safety of two lipid emulsions for parenteral nutrition in postsurgical critically ill patients: Clinoleic(R) versus SMOFlipid(R)

INTRODUCCIÓN: las emulsiones lipídicas (EL) pueden asociar distintos efectos inmunomoduladores dependiendo de su composición de ácidos grasos. Las EL enriquecidas con aceite de pescado y las basadas en aceite de oliva (EBAO) han mostrado ventajas frente a las derivados del aceite de soja, aunque son muy escasos los estudios que las comparan entre sí y no existe ninguno en pacientes críticos quirúrgicos. OBJETIVOS: demostrar la no inferioridad de la eficacia terapéutica de SMOFlipid(R) (enriquecida con aceite de pescado) frente a Clinoleic(R) (EBAO) en relación con la aparición de infecciones nosocomiales y otros parámetros evolutivos. Demostrar la no inferioridad de la seguridad de SMOFlipid(R) frente a Clinoleic(R) expresada como aparición de mortalidad y acontecimientos adversos. MATERIAL Y MÉTODO: ensayo clínico de fase III, de no inferioridad, realizado en pacientes críticos posquirúrgicos. Los sujetos se aleatorizaron para recibir SMOFlipid(R) o Clinoleic(R). Para comparar variables cualitativas se obtuvieron la frecuencia y el porcentaje de casos, realizando la prueba del chi cuadrado o el test de Fisher. Las medias entre dos grupos se compararon empleando el test de la "t" de Student. Se consideró estadísticamente significativo un valor de p menor de 0,05. Para el análisis principal de no inferioridad de la variable principal se aplicaron los test de Farrington-Manning, Miettinen-Nurminen y Gart-Nam. RESULTADOS: se incluyeron 73 pacientes, de los cuales 37 recibieron Clinoleic(R) y 36 SMOFlipid(R). En la variable "disminución de infecciones nosocomiales", SMOFlipid(R) demostró no ser inferior a Clinoleic(R). En la variable principal "mortalidad", SMOFlipid(R) demostró no ser inferior a Clinoleic(R). Tampoco existieron diferencias estadísticamente significativas en cuanto a la aparición de efectos adversos. CONCLUSIONES: en nuestro estudio, SMOFlipid(R) demostró no ser inferior a Clinoleic(R) en términos de eficacia y seguridad

INTRODUCTION: a lipid emulsion (LE) may result in different immunomodulatory effects depending on its fatty acid composition. LEs enriched with fish oil and those based on olive oil (OOBE) have shown advantages over those derived from soybean oil, although very few studies have compared these with each other, and none was performed in critically ill surgical patients. OBJECTIVES: to demonstrate non-inferiority for the therapeutic efficacy of SMOFlipid(R) (enriched with fish oil) versus Clinoleic(R) (OOBE) in relation to the occurrence of nosocomial infection and other evolutionary parameters. To demonstrate non-inferiority in the safety profile of SMOFlipid(R) versus Clinoleic(R) in terms of mortality and adverse events. MATERIAL AND METHOD: a phase-III, non-inferiority clinical trial performed in critically ill postsurgical patients. The subjects were randomized to receive SMOFlipid(R) or Clinoleic(R). For comparison of qualitative variables case frequencies and percentages were obtained using the Chi-squared test or Fisher's exact test. Means were compared between groups using Student's t-test. A p-value lower than 0.05 was considered statistically significant. The Farrington-Manning, Miettinen-Nurminen, and Gart-Nam tests were applied in the main non-inferiority analysis of the primary endpoint. RESULTS: during de inclusion period 73 patients were selected, 37 of whom received Clinoleic(R) and 36 SMOFlipid(R). Regarding the variable "decrease in nosocomial infections", SMOFlipid(R) proved to be non-inferior to Clinoleic(R). Regarding the main variable "mortality", SMOFlipid(R) proved to be non-inferior to Clinoleic(R). There were no statistically significant differences in the occurrence of adverse effects either. CONCLUSIONS: in our study, SMOFlipid(R) proved to be non-inferior to Clinoleic(R) in terms of efficacy and safety

[Effectiveness and safety of two lipid emulsions for parenteral nutrition in postsurgical critically ill patients: Clinoleic® versus SMOFlipid®]. / Eficacia y seguridad de dos emulsiones lipídicas de nutrición parenteral en pacientes críticos posquirúrgicos: Clinoleic® frente a SMOFlipid®.

INTRODUCTION: Introduction: a lipid emulsion (LE) may result in different immunomodulatory effects depending on its fatty acid composition. LEs enriched with fish oil and those based on olive oil (OOBE) have shown advantages over those derived from soybean oil, although very few studies have compared these with each other, and none was performed in critically ill surgical patients. Objectives: to demonstrate non-inferiority for the therapeutic efficacy of SMOFlipid® (enriched with fish oil) versus Clinoleic® (OOBE) in relation to the occurrence of nosocomial infection and other evolutionary parameters. To demonstrate non-inferiority in the safety profile of SMOFlipid® versus Clinoleic® in terms of mortality and adverse events. Material and method: a phase-III, non-inferiority clinical trial performed in critically ill postsurgical patients. The subjects were randomized to receive SMOFlipid® or Clinoleic®. For comparison of qualitative variables case frequencies and percentages were obtained using the Chi-squared test or Fisher's exact test. Means were compared between groups using Student's t-test. A p-value lower than 0.05 was considered statistically significant. The Farrington-Manning, Miettinen-Nurminen, and Gart-Nam tests were applied in the main non-inferiority analysis of the primary endpoint. Results: during de inclusion period 73 patients were selected, 37 of whom received Clinoleic® and 36 SMOFlipid®. Regarding the variable "decrease in nosocomial infections", SMOFlipid® proved to be non-inferior to Clinoleic®. Regarding the main variable "mortality", SMOFlipid® proved to be non-inferior to Clinoleic®. There were no statistically significant differences in the occurrence of adverse effects either. Conclusions: in our study, SMOFlipid® proved to be non-inferior to Clinoleic® in terms of efficacy and safety.

INTRODUCCIÓN: Introducción: las emulsiones lipídicas (EL) pueden asociar distintos efectos inmunomoduladores dependiendo de su composición de ácidos grasos. Las EL enriquecidas con aceite de pescado y las basadas en aceite de oliva (EBAO) han mostrado ventajas frente a las derivados del aceite de soja, aunque son muy escasos los estudios que las comparan entre sí y no existe ninguno en pacientes críticos quirúrgicos. Objetivos: Demostrar la no inferioridad de la eficacia terapéutica de SMOFlipid® (enriquecida con aceite de pescado) frente a Clinoleic® (EBAO) en relación con la aparición de infecciones nosocomiales y otros parámetros evolutivos. Demostrar la no inferioridad de la seguridad de SMOFlipid® frente a Clinoleic® expresada como aparición de mortalidad y acontecimientos adversos. Material y método: ensayo clínico de fase III, de no inferioridad, realizado en pacientes críticos posquirúrgicos. Los sujetos se aleatorizaron para recibir SMOFlipid® o Clinoleic®. Para comparar variables cualitativas se obtuvieron la frecuencia y el porcentaje de casos, realizando la prueba del chi cuadrado o el test de Fisher. Las medias entre dos grupos se compararon empleando el test de la "t" de Student. Se consideró estadísticamente significativo un valor de p menor de 0,05. Para el análisis principal de no inferioridad de la variable principal se aplicaron los test de Farrington-Manning, Miettinen-Nurminen y Gart-Nam. Resultados: se incluyeron 73 pacientes, de los cuales 37 recibieron Clinoleic® y 36 SMOFlipid®. En la variable "disminución de infecciones nosocomiales", SMOFlipid® demostró no ser inferior a Clinoleic®. En la variable principal "mortalidad", SMOFlipid® demostró no ser inferior a Clinoleic®. Tampoco existieron diferencias estadísticamente significativas en cuanto a la aparición de efectos adversos. Conclusiones: en nuestro estudio, SMOFlipid® demostró no ser inferior a Clinoleic® en términos de eficacia y seguridad.

[Not Available]. / Estudio comparativo de la eficacia y seguridad de una nutrición parenteral formulada con dos lípidos distintos: SMOFlipid® frente a Clinoleic®. Estudio preliminar.

Introducción: la composición lipídica de las fórmulas de nutrición parenteral (NP) se postula como posible factor de evolución clínica.Objetivo: evaluar las diferencias en eficacia y seguridad de dos emulsiones lipídicas en NP.Material y métodos: estudio clínico prospectivo de pacientes posquirúrgicos sometidos a NP durante más de 7 días en un periodo de 2 años. Se administraron de forma indistinta 2 tipos de emulsiones lipídicas: enriquecida con ácidos grasos omega 3 (SMOFlipid Fresenius Kabi®) o con ácido oleico omega 9 (Clinoleic Baxter®). Se analizaron variables epidemiológicas, analíticas, complicaciones infecciosas y mortalidad.Resultados: se estudió un total de 154 pacientes con edad media de 64,36 ± 13,73 años, de los que 95 eran hombres (61%), 78 (51%) recibieron SMOFlipid® y 76 (49%) Clinoleic®. La estancia media fue de 16,91 ± 4,23 días, la duración de la NP 9,68 ± 3,25 días y la mortalidad del 11%. Se diagnosticaron 58 (37%) infecciones. No existieron diferencias significativas en cuanto a los parámetros analíticos lipídicos, hepáticos o nutricionales (medidos al inicio y al 7.º día) ni en su evolución (estancia media, complicaciones infecciosas ni mortalidad) entre los dos grupos de pacientes.Conclusión: los pacientes sometidos a NP presentan similares características evolutivas con independencia de la emulsión lipídica utilizada. La bibliografía actual apunta a un beneficio de la disminución del aporte de ácidos grasos omega 9, pero no se han encontrado diferencias significativas entre las fórmulas comparadas.

Estudio comparativo de la eficacia y seguridad de una nutrición parenteral formulada con dos lípidos distintos: SMOFlipid® frente a Clinoleic®. Estudio preliminary / Comparative study on the efficacy and safety of parenteral nutrition formulated with two different fat emulsions: SMOFlipid® compared with Clinoleic®. Preliminary study

Introducción: la composición lipídica de las fórmulas de nutrición parenteral (NP) se postula como posible factor de evolución clínica. Objetivo: evaluar las diferencias en eficacia y seguridad de dos emulsiones lipídicas en NP. Material y métodos: estudio clínico prospectivo de pacientes posquirúrgicos sometidos a NP durante más de 7 días en un periodo de 2 años. Se administraron de forma indistinta 2 tipos de emulsiones lipídicas: enriquecida con ácidos grasos omega 3 (SMOFlipid Fresenius Kabi®) o con ácido oleico omega 9 (Clinoleic Baxter®). Se analizaron variables epidemiológicas, analíticas, complicaciones infecciosas y mortalidad. Resultados: se estudió un total de 154 pacientes con edad media de 64,36 ± 13,73 años, de los que 95 eran hombres (61%), 78 (51%) recibieron SMOFlipid® y 76 (49%) Clinoleic®. La estancia media fue de 16,91 ± 4,23 días, la duración de la NP 9,68 ± 3,25 días y la mortalidad del 11%. Se diagnosticaron 58 (37%) infecciones. No existieron diferencias significativas en cuanto a los parámetros analíticos lipídicos, hepáticos o nutricionales (medidos al inicio y al 7.º día) ni en su evolución (estancia media, complicaciones infecciosas ni mortalidad) entre los dos grupos de pacientes. Conclusión: los pacientes sometidos a NP presentan similares características evolutivas con independencia de la emulsión lipídica utilizada. La bibliografía actual apunta a un beneficio de la disminución del aporte de ácidos grasos omega 9, pero no se han encontrado diferencias significativas entre las fórmulas comparadas (AU)

Introduction: The fat composition of parenteral nutrition formulae has been put forward as a possible factor in clinical evolution. Objective: To evaluate the differences in efficacy and safety of two (2) fat emulsions for parenteral nutrition. Material and methods: Prospective clinical study of post-surgery patients under PN for more than seven days in a two-year period. Two types of fat emulsions were administered indistinctively. One is enriched with omega 3 fatty acids (SMOFlipid Fresenius Kabi®), the other one is enriched with omega 9 oleic acid (Clinoleic Baxter®). Epidemiological and analytical variables, infectious complications and mortality were analysed. Results: A total of 154 patients were studied. Their average age was 64.36 ± 13.73 years; 95 were men (61%). Out of the total number, 78 (51%) were given SMOFlipid® and 76 (49%) Clinoleic®. Average stay was 16.91 ± 4.23 days, parenteral nutrition was administered for 9.68 ± 3.25 days, mortality was 11%. 58 (37%) infections were diagnosed. When measured on the first (1st) and seventh (7th) days, there were no significant differences in regard to the lipid, hepatic or nutritional parameters, nor in their evolution (average stay, infectious complications, or mortality) between the two groups of patients. Conclusion: Patients on parenteral nutrition show similar evolutionary characteristic, independently of the fat emulsion administered. Current bibliography would suggest that a benefit could be gained from reducing the administration of omega 9 fatty acids, but no significant differences were found when comparing the two formulae (AU)

Mejora de la calidad en el consentimiento informado / Enhancement of informed consent quality / Melhora da qualidade no consentimento informado

Objetivo: Aplicar un círculo de mejora al consentimiento informado para la transfusión de hemoderivados. Pacientes y Método: Durante 10 meses se incluyeron 577 pacientes intervenidos en el Hospital General Reina Sofía de Murcia. Seleccionamos 6 criterios relacionados con el cumplimiento de la normativa sobre transfusiones. Tras el análisis de calidad, se aplicaron medidas correctoras y se reevaluaron los criterios. Los datos se compararon con los estándares en ambos periodos y entre periodos. En la primera evaluación se obtuvo un pobre cumplimiento de los criterios. Basándonos en el análisis de factores asociados al incumplimiento y la priorización resultante del diagrama de Pareto, el plan de intervención se dividió en actividad docente y modificaciones organizativas. Resultados: Todos los criterios estaban por debajo del estándar (p<0,001). En la segunda evaluación el cumplimiento de todos los criterios mejoró significativamente respecto de la primera; aun así los resultados continúan, también significativamente, por debajo de los estándares establecidos. Conclusiones: El cumplimiento de los 6 criterios era mínimo al inicio del estudio; las medidas correctoras fueron adecuadas, puesto que mejoraron todos ellos en la segunda evaluación, pero es necesario insistir en estas medidas ya que continuamos por debajo del estándar establecido.

Aim: To apply an enhancement circle for informed consent for transfusion of blood derivatives. Patients and Method: During 10 months 577 intervened patients were included in General Hospital Reina Sofia of Murcia, Spain. Six criteria were selected related to compliance with transfusion norms. After quality analysis, corrected measures were taken and the criteria were re evaluated. Data were compared with standards in both periods and between periods. In the first evaluation a poor compliance to criteria was observed. Based on the analysis of factors associated to lack of compliance and the resulting priorization from Pareto’s diagram, the intervention plan was divided in teaching activity and management modifications. Results: all criteria were under the standard (p<0.001). In the second evaluation, compliance for all criteria was significantly enhance with respect to the first; but nevertheless, results continue, also significantly, under established standards. Conclusions: Compliance to the six criteria was minimum at the beginning of the study; corrected measures were adequate, since they enhance all of them in the second evaluation, but it is necessary to insist in these measures since we continue under the established standard.

Objetivo: Aplicar um círculo de melhora ao consentimento informado para a transfusão de hemoderivados. Pacientes e Método: Durante 10 meses foram incluídos 577 pacientes internados no Hospital General Reina Sofía de Murcia. Selecionamos 6 critérios relacionados com o cumprimento da norma sobre transfusões. Após a análise de qualidade, foram aplicadas medidas corretoras e se reavaliaram os critérios. Os dados foram comparados com os padrões em ambos periodos e entre periodos. Na primeira avaliação se obteve um pobre cumprimento dos critérios. Baseando-nos na análise de fatores associados ao incumprimento e a priorização resultante do diagrama de Pareto, o plano de intervenção se dividiu em atividade docente e modificações organizativas. Resultados: Todos os critérios estavam abaixo do padrão (p<0,001). Na segunda avaliação o cumprimento de todos os critérios melhorou significativamente com respeito à primeira; ainda assim os resultados continuam, também significativamente, abaixo dos padrões estabelecidos. Conclusões: O cumprimento dos 6 critérios era mínimo ao início do estudo; as medidas corretoras foram adequadas, posto que melhoraram todos eles na segunda avaliação, porém é necessário insistir nestas medidas já que continuamos abaixo do padrão estabelecido.

Fatal heat stroke in a schizophrenic patient.

Objective. The case of a patient who developed a fatal post-exertional heat stroke is reported. Case Report. A 20-year-old man with a history of morbid obesity, hypertension, and schizophrenia was admitted to our intensive care unit because of multiorgan failure due to severe heat stroke. He had been working under the sun. Treatment included aggressive body cooling but, in spite of the best supportive care, the patient succumbed in a few hours. We concluded that the adverse event was possibly associated with his obesity and the use of antipsychotics. Histological evaluation revealed lesions consistent with severe hyperthermia and shock. Conclusions. Heat stroke is an uncommon clinical entity characterized by systemic heat and loss of the body's normal mechanisms for dealing with heat stress, such as sweating and temperature control. When heat stroke is diagnosed early and supportive care begins promptly the prognosis is optimal but it becomes a life-threatening disease when treatment is delayed. Lack of physical acclimatization and the use of certain medications that interfere with salt and water balance can impair thermoregulation under conditions of high environmental temperature. Health professionals must be adequately prepared to prevent, recognise, and treat them urgently.

[Quality assessment and improvement in the indication and management of parenteral nutrition in a general surgery unit]. / Evaluación y mejora de la calidad en la indicación y el manejo de la nutrición parenteral en un servicio de cirugía general.

OBJECTIVE: To analyze the degree of compliance with a variety of internationally accepted standards defined for Total Parenteral Nutrition (TPN) quality control in our Surgery Department. PATIENTS AND METHOD: Prospective study of patients treated with TPN over two years in the department of surgery of a university teaching hospital (n = 72). Assessment of quality was performed by measurements of compliance using 19 criteria. The criteria were divided into three groups according to characteristics of TPN standardisation: this must be "appropriate" to the nutritional requirements of the patient, "safe" in order to prevent complications and "accurate" in its daily programming. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria over six months, paying particular attention to those criteria which had the highest percentage of errors in the study carried out using a Pareto analysis. During a third period of six months the information on all 19 criteria was gathered again and the improvement with regard to the standard values and to the compliance in the first period (using the value of z) was evaluated. RESULTS: The compliance with seven criteria was significantly below standard values: all those of the "appropriate" group, except the criteria "type of diet" and "composition of the diet", and the criteria "absence of complications" of the "safe" group, which was also the one with the highest number of grouped non-compliances. In the second period all the below standard criteria improved with compared to the first period. The criteria "time of fasting", "concordance" and "duration" were significantly improved. The criteria "time of fasting", "duration" and "latency" reached the standard. The rest of criteria that reached their standard in the first evaluation maintained the same results. CONCLUSIONS: Corrective measures introduced were effective since all the below standard criteria improved, including metabolic complications. Notwithstanding, it is necessary to continue in this line to improve the criteria still below standard.

Evaluación y mejora de la calidad en la indicación y el manejo de la nutrición parenteral en un servicio de cirugía general / Quality assessment and improvement in the indication and management of parenteral nutrition in a general surgery unit

Objetivo. Aplicar un ciclo de evaluación y mejora del cumplimiento de diversos criterios de calidad en la indicación y manejo de la nutrición parenteral total (NPT) en un servicio quirúrgico. Pacientes y método. Estudio prospectivo en 72 pacientes tratados con NPT durante 2 años en el Servicio de Cirugía General del Hospital General Universitario Reina Sofía de Murcia. El ciclo de mejora se realizó en dos períodos: en el primero, de 1 año de duración, se analizó el cumplimiento (porcentaje e intervalo de confianza [IC] del 95%) de 19 criterios respecto a sus estándares internacionalmente aceptados (significación estadística según valor de z para el modelo de una cola) en todas las dietas de NPT prescritas en nuestro servicio de cirugía general. Dichos estándares estaban divididos en tres grupos, “ajustada” (indicación correcta de la nutrición), “segura” (ausencia de complicaciones) y “exacta” (correspondencia de la dieta administrada con la prescrita). Durante los 6 meses siguientes, tras analizar las posibles causas de los incumplimientos, se aplicaron las medidas oportunas para intentar solucionarlos. En un segundo periodo de 6 meses se recogieron nuevamente los datos de los 19 criterios y se evaluó la mejora tanto respecto al estándar como respecto al cumplimiento del primer período (mediante el valor de z para una cola). Resultados. Siete criterios se encontraban significativamente por debajo del estándar: todos los del grupo “ajustada”, salvo los criterios “tipo de dieta” y “composición de la dieta”, y el criterio “ausencia de complicaciones” del grupo “segura”, que era además el que mayor número de incumplimientos agrupaba. En el segundo período, todos los criterios por debajo de su estándar mejoraron respecto al primero y en especial los criterios “tiempo de ayuno”, “concordancia” y “duración” mejoraron de forma estadísticamente significativa. Alcanzaron su estándar los criterios “tiempo de ayuno”, “duración” y “latencia”. El resto de los criterios, que alcanzaron su estándar en la primera evaluación, continuaban con los mismos resultados. Conclusiones. Las medidas correctoras introducidas fueron eficaces, ya que se mejoró en todos los criterios por debajo de sus estándares, incluidas las complicaciones metabólicas. A pesar de ello es necesario continuar en la línea de actuación para mejorar los criterios aún por debajo de su estándar The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Objective. To analyze the degree of compliance with a variety of internationally accepted standards defined for Total Parenteral Nutrition (TPN) quality control in our Surgery Department. Patients and method. Prospective study of patients treated with TPN over two years in the department of surgery of a university teaching hospital (n = 72). Assessment of quality was performed by measurements of compliance using 19 criteria. The criteria were divided into three groups according to characteristics of TPN standardisation: this must be “appropriate” to the nutritional requirements of the patient, “safe” in order to prevent complications and “accurate” in its daily programming. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria over six months, paying particular attention to those criteria which had the highest percentage of errors in the study carried out using a Pareto analysis. During a third period of six months the information on all 19 criteria was gathered again and the improvement with regard to the standard values and to the compliance in the first period (using the value of z) was evaluated. Results. The compliance with seven criteria was significantly below standard values: all those of the “appropriate” group, except the criteria “type of diet” and “composition of the diet”, and the criteria “absence of complications” of the “safe” group, which was also the one with the highest numer of grouped non-complinces. In the second period all the below standard criteria improved with compared to the first period. The criteria “time of fasting”, “concordance” and “duration” were significantly improved. The criteria “time of fasting”, “duration” and “latency” reached the standard. The rest of criteria that reached their standard in the first evaluation maintained the same results. Conclusions. Corrective measures introduced were effective since all the below standard criteria improved, including metabolic complications. Notwithstanding, it is necessary to continue in this line to improve the criteria still below standard The increased use of biomaterials for the repair of abdominal wall hernias has achieved a significant reduction in recurrences and consequently improved the quality of life of patients. However, the appearance of complications such as infection may require the implanted prosthetic material to be removed in a considerable number of patients. A possible treatment option in areas compromised by infection is the implant a biocompatible prosthetic material to generate, or induce the formation of a support tissue so that, in a second stage, the definitive repair of the parietal defect may be undertaken. This is the main goal of bioprostheses. These implants are composed of collagen of animal (usually porcine) or human origin. They should be acellular and fully biocompatible so that they induce a minimal foreign body reaction and immune response (AU)

Evaluación y mejora del cumplimiento de la normativa sobre consentimiento informado para la transfusión de hemoderivados en un servicio de cirugía general / Assessment of improvements in compliance with the guidelines on informed consent for the transfusion of blood derivatives in a general surgery department

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Quality evaluation of total parenteral nutrition in an acute care setting.

OBJECTIVE: To analyse the degree of compliance with internationally accepted standards defined for total parenteral nutrition (TPN) quality control in our hospital. The problems of quality which exist must be detected and possible solutions put into practice. PATIENTS AND METHOD: Retrospective study of critically ill patients treated with TPN during two years in a university teaching hospital (n=92). Assessment of quality was performed through measurements of compliance using 20 criteria. These were evaluated both individually and gathered in three categories: appropriate, safe and accurate TPN. Three summary/indicators were also established which assessed simultaneous compliance with all the criteria in each group. Criteria compliance was compared to standards values. Patient (age, sex, diabetes) and process (TPN indication, patient's outcome, type of diet used) variables were analysed (using logistic regression models) as factors potentially associated with compliance with the quality criteria. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria, paying particular attention to those criteria which presented the highest percentage of errors in the study carried out using a Pareto analysis. RESULTS: Compliance of six criteria was significantly below standard values. Simultaneous compliance of all criteria by group was 17% in adjusted TPN, 38% in safe TPN and 94% in exact TPN. There was a negative association between an age over 65 years and both a correct indication of TPN (OR: 9.4) and the indicator compliance of all criteria in the adjusted TPN group (OR: 2.9). The absence of metabolic complications was influenced (P<0.05) by the use of standardized diets (OR: 0.3). Effects of the change: the simultaneous compliance with all the criteria of a group improved in all three groups, but this was statistically significant in the 'appropriate' TPN and 'safe' TPN groups. The criteria analysed individually improved after the corrective measures in five of the six criteria which had been below standard in the first evaluation. CONCLUSIONS: The correct understanding and application of the indications, physiology and potential complications of TPN constitute the hub of the improvement process.

Alta prevalencia de la desnutrición en ancianos españoles ingresados en un hospital general y factores asociados / High prevalence of undernutrition in spanish elders admitted to a general hospital and associated factors

El propósito del estudio fue evaluar la situación nutricional del enfermo anciano hospitalizado empleando el Mininutritional Assessment (MNA) y diversos parámetros nutricionales, conocer la prevalencia de la malnutrición entre ellos y valorar la correlación de la malnutrición con algunas características epidemiológicas de los pacientes estudiados para definir el grupo con mayor riesgo de padecerla. Se realizó un estudio transversal sobre 200 pacientes ancianos ingresados en el Hospital USP San Carlos (Murcia, España) durante un periodo de 3 meses, mediante una encuesta que incluía variables demográficas y el test MNA. También se recogieron los niveles séricos de albúmina y transferrina y el recuento linfocitario en sangre. En el análisis estadístico se utilizó la X² de Pearson para variables cualitativas, la t de Student para muestras independientes y el coeficiente de Spearman. La media de edad fue de 80,72 DE 7,43 años. El peso medio fue de 63,41 DE 19,57 kg., la talla media 160,93 DE 8,36 cm y el Indice de Masa Corporal de 24,27 DE 7,31. Las cifras medias de albúmina, transferrina y linfocitos totales fueron 3,09 DE 0,5 g/l, 1,69 DE 0,37 mg/dl y 1412 mm3 respectivamente. El resultado del MNA fue de 15,9 DE 6,21 y un 50 por ciento (n=100) de los enfermos valorados mostró algún grado de malnutrición. El análisis de correlación demostró asociación estadísticamente significativa (p<0,001) entre valores de malnutrición del MNA y valores por debajo de lo normal de los parámetros bioquímicos e inmunológicos. Los pacientes que presentan enfermedades crónicas, mayor deterioro físico y mental y menor autosuficiencia están desnutridos o en alto riesgo de estarlo. La valoración nutricional debe realizarse como rutina al ingreso de los ancianos en el hospital para detectar y tratar precozmente cualquier signo de malnutrición

Presentation of Degos syndrome as acute small-bowel perforation.

Malignant atrophic papulosis is an uncommon vasculopathy affecting multiple systems and frequently associated with a poor prognosis. We describe a 56-year-old patient with this rare disorder whose death was the result of intestinal involvement. Clinical diagnostic features of malignant atrophic papulosis as well as the main therapeutic approaches suggested in the literature are presented herein.

[Parenteral nutrition in a general hospital: quality criteria and factors associated with compliance]. / Utilización de la nutrición parenteral total en un hospital general: criterios de calidad y factores asociados a su cumplimiento.

BACKGROUND AND OBJECTIVE: The aim of this study was to analyze the quality in the use of total parenteral nutrition (TPN). PATIENTS AND METHOD: Retrospective study of patients treated with TPN during one year in a general hospital (n = 92). Assessment of quality was performed through measurements of compliance using 20 criteria. These were analyzed both individually and gathered in 3 groups: adjusted (correct indication), safe (absence of complications) and exact TPN (when prescribed diet matched to the administered one). Criteria compliance was compared to standards values (% expected compliance for a quality service). Patient (age, sex, diabetes mellitus) and process (TPN indication, patient's outcome, type of diet) variables were analyzed (using logistic regression models) as potential factors associated with criteria compliance. RESULTS: Compliance of six criteria was significantly below standard values. Simultaneous compliance of all criteria by group was 17% (95% CI: 10-24) in adjusted TPN, 38% (95% CI: 29-47) in safe TPN, and 94% (95% CI: 90-98) in exact TPN. There was a negative association between an age over 65 years and both a correct indication of TPN (OR= 9.4; 95% CI: 1.1-79.8) and the indicator compliance of all criteria in the adjusted TPN group (OR: 2.9 95% CI: 1.03-8.4). The absence of metabolic complications was influenced (p < 0.05) by the use of standardized diets (OR = 0.3; 95% CI: 0.1-0.9). CONCLUSIONS: Quality defects were mainly related to the prescription and the frequency of metabolic complications. In general, TPN is used less appropriately when patients are older than 65 years, and metabolic complications are more frequent when standardized diets are used.

Utilización de la nutrición parenteral total en un hospital general: criterios de calidad y factores asociados a su cumplimiento / Parenteral nutrition in a general hospital: quality criteria and factors associated with compliance

FUNDAMENTO Y OBJETIVO: Evaluar la calidad de la utilización de la nutrición parenteral total (NPT) y sus factores asociados.PACIENTES Y MÉTODO: Estudio retrospectivo a un año de todos los pacientes tratados con NPT en un hospital general (n = 92). Se analiza el cumplimiento aislado y simultáneo de 20 criterios divididos en tres grupos: NPT 'ajustada' (correcta indicación), 'segura' (ausencia de complicaciones) y 'exacta' (correspondencia de la dieta administrada con la prescrita), y se comparan respecto de sus estándares. En el análisis de factores asociados, mediante modelos de regresión logística, se consideran variables del paciente (edad, sexo, presencia de diabetes mellitus) y del proceso asistencial (motivo de la NPT, destino del paciente y tipo de dieta).RESULTADOS: Se encontraron 6 criterios significativamente por debajo del estándar. El cumplimiento simultáneo de todos los criterios fue del 17 per cent (intervalo de confianza [IC] del 95 per cent, 1024) en NPT 'ajustada', del 38 per cent (IC del 95 per cent, 29-47) en 'segura' y del 94 per cent (IC del 95 per cent, 90-98) en 'exacta'. La edad mayor de 65 años influye negativamente (p < 0,05) en la correcta indicación de la NTP (odds ratio [OR] = 9,4; IC del 95 per cent, 1,1-79,8), así como en el indicador 'cumple todos los criterios' del grupo 'ajustada' (OR = 2,9; IC del 95 per cent, 1,03-8,4). La utilización de dietas estandarizadas influye negativamente (p < 0,05) en la ausencia de complicaciones metabólicas (OR = 0,3; IC del 95 per cent, 0,1-0,9).CONCLUSIONES: Las principales anomalías se relacionan con la prescripción y con la aparición de complicaciones metabólicas. En general, la NPT se emplea peor en mayores de 65 años y aparecen más complicaciones metabólicas cuando se utilizan dietas estandarizadas (AU)

Latrodectismo mortal en un anciano / Latrodectism in an elder man

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