El residente como docente: percepción de estudiantes de medicina de una universidad española / The resident as teacher: medical students’ perception in a Spanish university

Fundamento y objetivos. El médico residente desempeña una labor importante, aunque escasamente evaluada, en la enseñanza del estudiante de medicina. El objetivo de este estudio fue conocer la opinión de los estudiantes sobre la actividad docente del residente. Material y método. Encuesta autocumplimentada por estudiantes de medicina de la Universidad de Alcalá (España) durante el último año de su formación universitaria. Se evaluó la opinión de los estudiantes en relación con las habilidades docentes y asistenciales de los residentes y de los facultativos especialistas según una escala de Likert de 5 puntos. Resultados. Se obtuvieron 104 encuestas. Un 69,9% de los alumnos percibían al residente como fuente de más de la mitad de lo aprendido durante sus prácticas. Los estudiantes piensan que la labor docente del residente no está suficientemente reconocida (94,2%), creen necesaria la adquisición de habilidades docentes durante la residencia (82,7%) y se muestran favorables a tutorizar a alumnos de cursos anteriores (88,5%). Además, puntúan mejor al residente en habilidades relacionales en comparación con los facultativos especialistas. Conclusiones. Existe una percepción positiva del residente como docente entre los estudiantes de medicina, lo que sugiere la necesidad de mejorar las habilidades docentes del residente (AU)

Background and objectives. Residents play an important but scanty assessed role in medical students teaching. The aim of this study was to assess the perception of medical students about residents’ teaching activity. Material and methods. Autofilled survey provided to medical students of the University of Alcalá (Spain) in the final year in their school of medicine. Student opinion about care and teaching abilities of residents and physicians was evaluated using a 5-point Likert scale. Results. 104 surveys were collected. A 69,9% of students consider that as much as 50% of their knowledge came from rounds with residents. Students believe that resident teaching lacks enough academical acknowledgment (94.2%); they estimate necessary to acquire teaching skills during residency (82,7%), and they would like to provide tutoring other medical students (88,5%). Students rated residents better than physicians on relational and motivational abilities. Conclusions. There is a positive view about resident as a teacher among medical students, which suggests the need to improve the resident's teaching skills (AU)

The resident as teacher: Medical students' perception in a Spanish university. / El residente como docente: percepción de estudiantes de medicina de una universidad española.

BACKGROUND AND OBJECTIVES: Residents play an important but scanty assessed role in medical students teaching. The aim of this study was to assess the perception of medical students about residents' teaching activity. MATERIAL AND METHODS: Autofilled survey provided to medical students of the University of Alcalá (Spain) in the final year in their school of medicine. Student opinion about care and teaching abilities of residents and physicians was evaluated using a 5-point Likert scale. RESULTS: 104 surveys were collected. A 69,9% of students consider that as much as 50% of their knowledge came from rounds with residents. Students believe that resident teaching lacks enough academical acknowledgment (94.2%); they estimate necessary to acquire teaching skills during residency (82,7%), and they would like to provide tutoring other medical students (88,5%). Students rated residents better than physicians on relational and motivational abilities. CONCLUSIONS: There is a positive view about resident as a teacher among medical students, which suggests the need to improve the resident's teaching skills.

Incidence of tuberculosis in HIV-infected patients receiving HAART: interaction between TST and CD4 count.

BACKGROUND: There may be an interaction between the CD4 count and the tuberculin skin test (TST) for the development of tuberculosis (TB) in human immunodeficiency virus (HIV) infected patients receiving highly active antiretroviral therapy (HAART). METHODS: Observational, cohort study of patients treated with HAART during the course of HIV infection in whom TB was confirmed by a positive culture result. Patients were stratified by TST and CD4 count. Univariate and multivariate analyses were performed to identify risk factors associated with the development of TB. RESULTS: The study included 1824 patients starting HAART, 339 (18.6%) of whom were TST-positive. After a median 473 days, 45 cases of TB had developed (1.9 cases per 100 person-years, 95%CI 1.38-2.54). The risk of developing TB increased significantly among patients with a positive TST (2.81, 95%CI 1.11-7.15), and in individuals with > or < 200 cells/µ l (1.37, 95%CI 0.44-4.21). By contrast, in the TST-negative group, the risk was significantly higher in patients with < 200 cells/µ l (16.64, 95%CI 2.16-127.6). CONCLUSIONS: TST-positive patients are at high risk of developing TB, irrespective of CD4 count. However, among TST-negative patients only those with a CD4 count < 200 cells/µ l have an appreciable risk of developing the disease.

¿Qué temas eligen los internistas jóvenes en las oposiciones? / No disponible

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[Assessing the use of proton pump inhibitors in an internal medicine department]. / Evaluación del uso de los inhibidores de la bomba de protones en un servicio de medicina interna.

INTRODUCTION: proton pump inhibitors (PPIs) block the H+/K+ ATPase enzyme in gastric wall cells, leading to an inhibition of both baseline and stimulated acid secretion. Appropriate indications include: Gastroesophageal reflux, acute upper gastrointestinal bleeding, erosive gastritis or esophagitis, dyspepsia, NSAID-related gastropathy, and stress ulcer prophylaxis in high risk patients. The aims of this study were to review the current indications of PPIs, and to evaluate their use in Guadalajara s University Hospital. MATERIAL AND METHODS: a transversal, analytic, randomized study was carried out during 2003 in our internal medicine department. A total of 208 medical records for 832 patients receiving PPIs were reviewed (25%). Mean age was 67 years (range: 16-92), 46.2% were females, and most frequent conditions were HBP, COPD, and DM. RESULTS: 34.6% of patients took PPIs before admission, their use being inappropriate in 68.1% of them. Among hospitalized patients 73.03% used PPIs inappropriately, and most of them had no such indication at discharge. CONCLUSIONS: results are in accordance with the literature, with a high frequency of incorrect PPI use; a more accurate use of PPIs is to be recommended to avoid side effects and drug interactions, and to provide a more efficient medical care.

Evaluación del uso de los inhibidores de la bomba de protones en un servicio de medicina interna / No disponible

Introducción: los inhibidores de la bomba de protones (IBP)bloquean la enzima H+/K+ ATPasa en las células parietales gástricas,logrando la inhibición de la secreción de ácido clorhídrico deforma basal como tras estimulación. Las indicaciones apropiadaspara su uso son: enfermedad por reflujo gastroesofágico, hemorragiadigestiva aguda, úlceras activas, gastritis o esofagitis erosiva,dispepsia, gastropatía por AINE, profilaxis de úlcera de estrésen pacientes de riesgo.El objetivo del estudio fue la revisión de las indicaciones de losIBP en nuestro medio y la evaluación de su utilización en el HospitalUniversitario de Guadalajara.Material y métodos: se realizó un estudio de corte transversalanalítico con selección aleatoria de los pacientes atendidos enel Servicio de Medicina Interna durante todo el año 2003. Se revisaronun total de 208 historias de 832 pacientes (un 25%) a losque se administraron IBP. La edad media fue de 67 años (rango16-92), el 46,2% fueron mujeres y las enfermedades subyacentesmás frecuentes fueron: HTA, EPOC y DM.Resultados: un 34,6% de los pacientes tomaban IBP antesdel ingreso. De estos, el 68,1% no tenía indicación. Durante el ingresose prescribió de forma inadecuada el IBP al 73,07% y alalta, se mantenía el IBP sin indicación correcta.Conclusiones: los resultados están en concordancia con losanteriormente publicados, manteniéndose una alta frecuencia deuso incorrecto de los IBP y siendo recomendable una utilizaciónmás racional para evitar los efectos secundarios, las interaccionescon otros fármacos y aportar una atención médica más eficiente

Introduction: proton pump inhibitors (PPIs) block the H+/K+ ATPase enzyme in gastric wall cells, leading to an inhibition of both baseline and stimulated acid secretion. Appropriate indications include: Gastroesophageal reflux, acute upper gastrointestinalbleeding, erosive gastritis or esophagitis, dyspepsia,NSAID-related gastropathy, and stress ulcer prophylaxis in high risk patients. The aims of this study were to review the current indications of PPIs, and to evaluate their use in Guadalajara’s University Hospital.Material and methods: a transversal, analytic, randomizedstudy was carried out during 2003 in our internal medicine department. A total of 208 medical records for 832 patients receiving PPIs were reviewed (25%). Mean age was 67 years (range: 16-92), 46.2% were females, and most frequent conditions were HBP, COPD, and DM. Results: 34.6% of patients took PPIs before admission, theiruse being inappropriate in 68.1% of them. Among hospitalized patients 73.03% used PPIs inappropriately, and most of them had no such indication at discharge.Conclusions: results are in accordance with the literature, with a high frequency of incorrect PPI use; a more accurate use of PPIs is to be recommended to avoid side effects and drug interactions, and to provide a more efficient medical care (AU)

[Clinical trial comparing efficacy and safety of four highly active antiretroviral therapy (HAART) in antiretroviral-naive treatment with advanced HIV infection]. / Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada.

BACKGROUND: Comparison of efficacy and safety of four highly active antiretroviral therapy regimens (HAART) including two nucleoside analogues (NA) and a protease inhibitor (PI) in HIV positive patients with advanced infection and antiretroviral naive. PATIENTS AND METHODS: Multicenter, randomized and open labeled clinical trial in ten community hospitals of Castilla-La Mancha and Madrid. Regimen 1 contains zidovudine (AZT), lamivudine (3TC) and indinavir (IDV) regimen 2 includes AZT, 3TC and ritonavir (RTV), regimen 3 was didanosine (DDI), estavudine (D4T) and IDV, and regimen 4 included DDI, D4T and RTV. Decrease in viral load of HIV (VC) has been assessed as primary endpoint and as secondary one, the increase of the numbers of CD4 lymphocytes, percentage of disease progression, adverse reactions and adherence. Measurements were made at baseline visit and at 6, 12, 24, 36 and 48 weeks. RESULTS: A total of 98 patients with a mean baseline CD4 count of 122 x 10(6)/l (range of 5-340) and a baseline viral load of 5.1 log copies/ml were included. At 48 weeks, a mean increase of the CD4 and decrease of the viral load without significant difference between the 4 regimens (103 cells/2.62 log in regimen 1; 169 cells/2.86 log in regimen 2; 171 cells/2.56 log in regimen 3 and 141 cells/1.71 log in regimen 4) were observed in the analysis of the patients in treatment. Treatment was discontinued due to adverse reactions: 24% in regimen 1, 48% in regimen 2, 26% in regimen 3 and 32% in regimen 4, without significant difference. Analyzing by PI groups, 41% of the patients with RTV and 25% of those with IDV discontinued treatment due to adverse effects. There was withdrawal from treatment due to disease progression in 7% of the RTV patients and in 9% of IDV patients. CONCLUSIONS: In the HIV positive patients with advanced infection, efficacy between the four regimens of HAART is similar, but there is a tendency to require more withdrawal due to adverse effects in the RTV group than in those of IDV, the two used as single PI.

Ensayo clínico comparativo de eficacia y seguridad de cuatro pautas de tratamiento antirretroviral de alta eficacia (TARGA) en pacientes naive con infección por VIH avanzada / Clinical trial comparing efficacy and safety of four highly active antiretroviral therapy (HAART) in antiretroviral-naive treatment with advanced HIV infection

Introducción. Comparación de la eficacia y seguridad de cuatro pautas de terapia antirretroviral de gran actividad (TARGA) incluyendo dos análogos de nucleósidos (AN) y un inhibidor de proteasa (IP) en pacientes con el virus de la inmunodeficiencia humana (VIH) con infección avanzada y naive a antirretrovirales. Pacientes y método. Ensayo clínico, multicéntrico, randomizado y abierto en diez hospitales comunitarios de Castilla-La Mancha y Madrid. La pauta 1 contenía zidovudina (ZDV), lamivudina (3TC) e indinavir (IDV); la pauta 2 incluía ZDV, 3TC y ritonavir (RTV); la pauta 3 era didanosina (DDI), estavudina (D4T) e IDV, y la pauta 4 incluía DDI, D4T y RTV. Se ha valorado como variable principal de respuesta el descenso de la carga viral del VIH (CV), y como variables secundarias: el aumento del número de linfocitos CD4, el porcentaje de progresión de la enfermedad, las reacciones adversas y la adherencia. Las determinaciones se realizaron en la visita basal y a las 6, 12, 24, 36 y 48 semanas. Resultados. Se incluyeron 98 pacientes con una media de CD4 basal de 122 x 106/l (rango de 5-340) y una carga viral basal de 5,1 log copias/ml. A las 48 semanas, en el análisis de los pacientes en tratamiento se observó un incremento medio de los CD4 y una disminución de la carga viral sin diferencia significativa entre las 4 pautas (103 células/2,62 log en la pauta 1, 169 células/ 2,86 log en la pauta 2, 171 células/2,56 log en la pauta 3 y 141 células/1,71 log en la pauta 4). Interrumpieron el tratamiento por reacciones adversas: el 24% en la pauta 1, el 48% en la pauta 2, el 26% en la pauta 3 y el 32% en la pauta 4, sin diferencias significativas. Analizando por grupos de IP el 41% de los pacientes con RTV y el 25% de los pacientes con IDV suspendieron el tratamiento por efectos adversos. Se produjo retirada del tratamiento por progresión de la enfermedad en el 7% de los pacientes con RTV y en el 9% de los pacientes con IDV. Conclusiones. En los pacientes VIH positivos con infección avanzada la eficacia entre cuatro pautas de TARGA es similar, pero existe una tendencia a precisar mayor retirada por efectos adversos en los grupos de RTV que en los de IDV, los dos usados como IP único

Background. Comparison of efficacy and safety of four highly active antiretroviral therapy regimens (HAART) including two nucleoside analogues (NA) and a protease inhibitor (PI) in HIV positive patients with advanced infection and antiretroviral naive. Patients and methods. Multicenter, randomized and open labeled clinical trial in ten community hospitals of Castilla-La Mancha and Madrid. Regimen 1 contains zidovudine (AZT), lamivudine (3TC) and indinavir (IDV) regimen 2 includes AZT, 3TC and ritonavir (RTV), regimen 3 was didanosine (DDI), estavudine (D4T) and IDV, and regimen 4 included DDI, D4T and RTV. Decrease in viral load of HIV (VC) has been assessed as primary endpoint and as secondary one, the increase of the numbers of CD4 lymphocytes, percentage of disease progression, adverse reactions and adherence. Measurements were made at baseline visit and at 6, 12, 24, 36 and 48 weeks. Results. A total of 98 patients with a mean baseline CD4 count of 122 x 106/l (range of 5-340) and a baseline viral load of 5.1 log copies/ml were included. At 48 weeks, a mean increase of the CD4 and decrease of the viral load without significant difference between the 4 regimens (103 cells/2.62 log in regimen 1; 169 cells/2.86 log in regimen 2; 171 cells/2.56 log in regimen 3 and 141 cells/1.71 log in regimen 4) were observed in the analysis of the patients in treatment. Treatment was discontinued due to adverse reactions: 24% in regimen 1, 48% in regimen 2, 26% in regimen 3 and 32% in regimen 4, without significant difference. Analyzing by PI groups, 41% of the patients with RTV and 25% of those with IDV discontinued treatment due to adverse effects. There was withdrawal from treatment due to disease progression in 7% of the RTV patients and in 9% of IDV patients. Conclusions. In the HIV positive patients with advanced infection, efficacy between the four regimens of HAART is similar, but there is a tendency to require more withdrawal due to adverse effects in the RTV group than in those of IDV, the two used as single PI

[Report of three cases of hyperlactacidemiae/lactic acidosis after treatment of hepatitis C with pegylated interferon and ribavirin in HIV coinfected patients]. / A propósito de tres casos de hiperlactacidemia/acidosis láctica tras el tratamiento de la hepatitis C con interferón pegilado y ribavirina en pacientes coinfectados por VIH.

The hepatitis C infection is highly prevalent among HIV-infected patients. As a direct consequence of the increased survival of these patients in the HAART era, liver disease and its long-term complications have became a genuine health problem in these patients. The treatment of chronic HCV hepatitis is associated with several secondary effects, hiperlactacidemiae/lactic acidosis is one of the most dangerous. It appears to be related with the association of ribavirin and ddI, d4T or AZT. These are three cases of hiperlactacidemiae/lactic acidosis collected during the first twelve months of treatment with pegylated interferon and ribavirin in University Hospital of Guadalajara.

A propósito de tres casos de hiperlactacidemia/acidosis láctica tras el tratamiento de la hepatitis C con interferón pegilado y ribavirina en pacientes coinfectados por VIH / Report of three cases of hyperlactacidemiae/lactic acidosis after treatment of hepatitis C with pegylated interferon and ribavirin in HIV coinfected patients

La infección por virus de la hepatitis C tiene una alta prevalencia entre las personas infectadas por VIH. Por su elevada tasa de evolución a la cronicidad, pudiendo progresar a cirrosis y carcinoma hepatocelular, y el incremento en la esperanza de vida de estos pacientes es necesario afrontar el tratamiento de esta coinfección.La asociación del TARGA con el interferón y la ribavirina produce interacciones y efectos adversos no bien documentados hasta el momento actual. La hiperlactacidemia/acidosis láctica es uno de los más potencialmente graves que parece asociado a la combinación de ribavirina con ddI, d4T o AZT.Se describen tres casos de hiperlactacidemia/ acidosis láctica recogidos en el Hospital Universitario de Guadalajara durante el tratamiento de la hepatitis C crónica en pacientes con infección por VIH. (AU)

Diabetes insípida nefrogénica secundaria a nefritis intersticial crónica asociada a tratamiento con mesalazina

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Supervivencia en España de las paradas cardíacas extrahospitalarias / Survival after extra-hospital cardiac arrest in Spain

Objetivo. Aumentar el conocimiento sobre la parada cardíaca extrahospitalaria (PCR-EH) en España. Método. Analizamos 6.684 episodios de PCR-EH publicados entre junio de 1987 y julio de 1999. Estudiamos los siguientes parámetros: intentos de resucitación, supervivencia inicial (llegada del paciente vivo al hospital), precoz (alta del hospital) y tardía (6 meses), así como la relación incidencia/supervivencia. Comparamos los resultados con 31.078 episodios publicados de PCR-EH incluidos en 31 referencias internacionales. Resultados. Se intentó la resucitación en 3.642 (54,5 por ciento). La edad media fue de 61 ñ 8 años; un 68,5 por ciento eran varones; más del 50 por ciento fueron presenciadas pero el testigo inició reanimación cardipulmonar (RCP) en el 12,5 por ciento. Los intervalos llamada-respuesta fueron menores de 10 min pero el 51,3 por ciento fueron ritmos bradiasistólicos. La incidencia fue de 24 PCR-EH tratadas por 100.000 habitantes/año; la supervivencia inicial fue del 26,2 por ciento (8/100.000 habitantes/año) y la precoz del 10,1 por ciento (2/100.000 habitantes/año), aumentando anualmente (r = 0,079, r = 0,082 y r = 0,211); la supervivencia tardía fue del 5,4 por ciento (1/100.000 habitantes/año), con descenso anual (r = -0,647). El porcentaje de pacientes dados de alta vivos no difieren globalmente de la bibliografía (10,7 por ciento), pero allí se describe un mayor número de PCREH tratadas (59 ñ 25/100.000 habitantes/año; t = 4,548; gl = 14; p < 0,001) y la curva incidencia/ supervivencia se desplaza a la derecha (mayor supervivencia a cualquier nivel de incidencia). Se detecta una considerable mortalidad evitable. Conclusiones. La efectividad de los equipos de emergencias españoles en el tratamiento de la parada cardíaca extrahospitalaria es comparable a la bibliografía internacional, pero con una incidencia menor y un aplanamiento del perfil de incidencia/supervivencia, lo que parece orientar hacia un escaso desarrollo de los primeros eslabones de la "cadena de supervivencia" (AU)