Variation Between Multidisciplinary Tumor Boards in Clinical Staging and Treatment Recommendations for Patients With Locally Advanced Non-small Cell Lung Cancer.

BACKGROUND: Accurate diagnosis and staging are crucial to ensure uniform allocation to the optimal treatment methods for non-small cell lung cancer (NSCLC) patients, but may differ among multidisciplinary tumor boards (MDTs). Discordance between clinical and pathologic TNM stage is particularly important for patients with locally advanced NSCLC (stage IIIA) because it may influence their chance of allocation to curative-intent treatment. We therefore aimed to study agreement on staging and treatment to gain insight into MDT decision-making. RESEARCH QUESTION: What is the level of agreement on clinical staging and treatment recommendations among MDTs in stage IIIA NSCLC patients? STUDY DESIGN AND METHODS: Eleven MDTs each evaluated the same 10 pathologic stage IIIA NSCLC patients in their weekly meeting (n = 110). Patients were selected purposively for their challenging nature. All MDTs received exactly the same clinical information and images per patient. We tested agreement in cT stage, cN stage, cM stage (TNM 8th edition), and treatment proposal among MDTs using Randolph's free-marginal multirater kappa. RESULTS: Considerable variation among the MDTs was seen in T staging (κ, 0.55 [95% CI, 0.34-0.75]), N staging (κ, 0.59 [95% CI, 0.35-0.83]), overall TNM staging (κ, 0.53 [95% CI, 0.35-0.72]), and treatment recommendations (κ, 0.44 [95% CI, 0.32-0.56]). Most variation in T stage was seen in patients with suspicion of invasion of surrounding structures, which influenced such treatment recommendations as induction therapy and type. For N stage, distinction between N1 and N2 disease was an important source of discordance among MDTs. Variation occurred between 2 patients even regarding M stage. A wide range of additional diagnostics was proposed by the MDTs. INTERPRETATION: This study demonstrated high variation in staging and treatment of patients with stage IIIA NSCLC among MDTs in different hospitals. Although some variation may be unavoidable in these challenging patients, we should strive for more uniformity.

Vulnerabilidad y atención sanitaria: Derecho y protocolos médicos / Vulnerability and health care. Law and medical protocols

El artículo aborda el análisis de los criterios de asignación de recursos sanitarios escasos durante la pandemia producida por el virus covid 19 en España. Se analiza críticamente la ausencia de una perspectiva jurídico-constitucional en la elaboración de tales criterios y se sugiere la incorporación del criterio de equidad como garantía del efectivo disfrute del derecho constitucional a la protección de la salud por parte de las personas vulnerables

The article deals with the analysis of the criteria for the allocation of scarce health resources during the pandemic produced by the covid 19 virus in Spain. It critically analyses the absence of a legal-constitutional perspective in the elaboration of such criteria and suggests the incorporation of the criterion of equity as a guarantee of the effective exercise of the constitutional right to health protection by vulnerable persons

An optimised dosing regimen versus a standard dosing regimen of vancomycin for the treatment of late onset sepsis due to Gram-positive microorganisms in neonates and infants aged less than 90 days (NeoVanc): study protocol for a randomised controlled trial.

BACKGROUND: Vancomycin has been used in clinical practice for over 50 years; however, validated, pharmacokinetic (PK) data relating clinical outcomes to different dosing regimens in neonates are lacking. Coagulase negative staphylococci (CoNS) are the most commonly isolated organisms in neonatal, late-onset sepsis (LOS). Optimised use to maximise efficacy while minimising toxicity and resistance selection is imperative to ensure vancomycin's continued efficacy. METHODS: NeoVanc is a European, open-label, Phase IIb, randomised, controlled, non-inferiority trial comparing an optimised vancomycin regimen to a standard vancomycin regimen when treating LOS known/suspected to be caused by Gram-positive organisms (excluding Staphylococcus aureus) in infants aged ≤ 90 days. Three hundred infants will be recruited and randomised in a 1:1 ratio. Infants can be recruited if they have culture confirmed (a positive culture from a normally sterile site and at least one clinical/laboratory criterion) or clinical sepsis (presence of any ≥ 3 clinical/laboratory criteria) in the 24 h before randomisation. The optimised regimen consists of a vancomycin loading dose (25 mg/kg) followed by 5 ± 1 days of 15 mg/kg q12h or q8h, dependent on postmenstrual age (PMA). The standard regimen is a 10 ± 2 day vancomycin course at 15 mg/kg q24h, q12h or q8h, dependent on PMA. The primary endpoint is a successful outcome at the test of cure visit (10 ± 1 days after the end of vancomycin therapy). A successful outcome consists of the patient being alive, having successfully completed study vancomycin therapy and having not had a clinical/microbiological relapse/new infection requiring treatment with vancomycin or other anti-staphylococcal antibiotic for > 24 h. Secondary endpoints include clinical/microbiological relapse/new infection at the short-term follow-up visit (30 ± 5 days after the initiation of vancomycin), evaluation of safety (renal/hearing), vancomycin PK and assessment of a host biomarker panel over the course of vancomycin therapy. DISCUSSION: Based on previous pre-clinical data and a large meta-analysis of neonatal, PK/pharmacodynamic data, NeoVanc was set up to provide evidence on whether a loading dose followed by a short vancomycin course is non-inferior, regarding efficacy, when compared to a standard, longer course. If non-inferiority is demonstrated, this would support adoption of the optimised regimen as a way of safely reducing vancomycin exposure when treating neonatal, Gram-positive LOS. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02790996. Registered on 7 April 2016. EudraCT, 2015-000203-89. Entered on 18 July 2016.

Decentralized care with generic direct-acting antivirals in the management of chronic hepatitis C in a public health care setting.

BACKGROUND & AIMS: The prevalence of anti-hepatitis C virus antibody in Punjab, India is 3.6%, with 728,000 people estimated to have viremic chronic hepatitis C (CHC). The Mukh-Mantri Punjab Hepatitis C Relief Fund, launched on 18th June 2016, provides no-cost generic direct-acting antivirals (DAAs) with sofosbuvir + ledipasvir ±â€¯ribavirin or sofosbuvir + daclatasvir ±â€¯ribavirin with the goal of eliminating CHC from Punjab. We assessed the safety and efficacy of decentralized treatment of CHC in a public health care setting. METHODS: Primary care providers from 3 university and 22 district hospitals were trained to provide algorithm-based DAA treatment and supervised by telehealth clinics conducted fortnightly. The diagnosis of cirrhosis was based on clinical and radiological evidence, including aspartate aminotransferase-to-platelet ratio index (APRI ≥2.0) and FIB-4 score (>3.25), or on liver stiffness measurement ≥12.5 kPa on Fibroscan®. RESULTS: We enrolled 48,088 individuals with CHC (63.8% male; mean age 42.1 years; 80.5% rural; 14.8% compensated cirrhosis; 69.9% genotype [GT] 3) between 18th June 2016 to 31st July 2018. While 36,250 (75.4%) patients completed treatment, 5,497 (11.4%) had treatment interruptions and 6,341 (13.2%) patients are currently ongoing treatment. Sustained virological response at 12 weeks after treatment completion (SVR12) was achieved in 91.6% of patients per protocol, 67.6% in intention-to-treat (ITT) analysis, where all interruptions were treated as failures, and 91.2% in a modified ITT analysis where all patients with successful SVR12 in the interruptions arm were included as cured. SVR12 rates in patients with and without cirrhosis and GT3 versus non-GT3 were comparable. The SVR12 rate was 84.4% in patients who had treatment interruptions. CONCLUSION: Decentralized care of patients with CHC using generic all-oral DAA regimens is safe and effective regardless of genotype or presence of cirrhosis. ClinicalTrials.gov number: NCT01110447. LAY SUMMARY: We assessed the safety and efficacy of public health care using no-cost all-oral generic direct-acting antiviral drugs against hepatitis C in the state of Punjab, India. The goal is elimination of chronic hepatitis C (CHC) by 2030 and involves primary care providers at 25 sites in the state. We enrolled 48,088 individuals (63.8% male; mean age 42.1 years; 80.5% rural; 14.8% compensated cirrhotic; 69.9% genotype 3) between 18th June 2016 to 31st July 2018. Cure was achieved in 91.6% of patients, demonstrating that decentralized care of CHC with generic all-oral regimens is safe and effective.

Using decision thresholds for ranking treatments in network meta-analysis results in more informative rankings.

OBJECTIVES: To evaluate how the rank probabilities obtained from network meta-analysis (NMA) change with the use of increasingly stringent criteria for the relative effect comparing two treatments which ranks one treatment better than the other. STUDY DESIGN AND SETTING: Systematic survey and reanalysis of published data. We included all systematic reviews (SRs) with NMA from the field of cardiovascular medicine that had trial-level data available, published in Medline up to February 2015. We reran all the NMAs and determined the probabilities of each treatment being the best. For the best treatment, we examined the effect on these probabilities of varying, what we call the decision threshold, the relative effect required to declare two treatments different. RESULTS: We included 14 SRs, having a median of 20 randomized trials and 9 treatments. The best treatments had probabilities of being best that ranged from 38% to 85.3%. The effect of changing the decision thresholds on the probability of a treatment being best varied substantially across reviews, with relatively little decrease (∼20 percentage points) in some settings but a decline to near 0% in others. CONCLUSION: Rank probabilities can be fragile to increases in the decision threshold used to claim that one treatment is more effective than another. Including these thresholds into the calculation of rankings may aid their interpretation and use in clinical practice.

Diagnostic protocols-A consultation tool still to be discovered.

RATIONALE: Experienced primary care physicians handle most illnesses to everyone's satisfaction despite limited resources of time and means. However, cases can be multifaceted in that harmless-presenting symptoms may also be warning signals or an indicator of a health disorder that too infrequently presents in family practice to be diagnosed correctly. On the basis of these observations, RN Braun developed 82 diagnostic protocols for a structured recording of various complaints. METHOD: All consultations during the years 2001 to 2014, in which 1 author (WF) had used diagnostic protocols in her single-handed practice, were analyzed retrospectively regarding reasons for encounter, diagnostic classification, and long-term outcome. RESULTS: During the period, a diagnostic protocol was used 1686 times. It was applied at a rate of approximately 5% of 2500 new complaints annually, most often (1366 times) for febrile conditions. In 320 consultations for other complaints, 43 different diagnostic protocols were applied. Among them, the "tabula diagnostica" for various undifferentiated symptoms was used most frequently (n = 54), followed by diagnostic protocols for headache (n = 45), dizziness (n = 36), precordial pain (n = 20), nonspecific abdominal pain (n = 15), low back pain (n = 14), hypertension (n = 12), diarrhea > 1 week (n = 12), epigastralgia (n = 11), depression (n = 10), polyarthralgia (n = 8), cough, and lower abdominal pain (each n = 7). A final diagnosis was established in less than 20% of cases. CONCLUSIONS: This observational study from routine practice gives an insight how diagnostic protocols helped to manage complex patient presentations. A broader use of diagnostic protocols could investigate the potential of this consultation tool to handle the complexity of primary health care. The use of a standardized diagnostic approach could stimulate research, in particular on managing common complaints/undifferentiated illness and their inherent diagnostic uncertainty.

Protocolo SANTIAGO. Planificación reparación endovascular de aorta (EVAR) en situaciones de urgencia / SANTIAGO protocol. Endovascular aortic repair planning in emergency situations

INTRODUCCIÓN: La reparación endovascular de los aneurismas de la aorta abdominal (EVAR) con éxito precisa la previa realización de una medición anatómica precisa basada en el estudio angio-TC aórtica. En situaciones de urgencia el tiempo para medición y planificación del caso es limitado y la disponibilidad del estudio en formato DICOM no siempre es posible. OBJETIVO: Presentar un protocolo de planificación desarrollado en nuestro centro que permite reducir el tiempo necesario para realizar las medidas en terapia EVAR de aneurismas de aorta abdominal (AAA) rotos en situaciones de urgencia y describir los resultados de nuestro centro antes y después de la aplicación de este protocolo. MÉTODO: Presentamos un análisis descriptivo de morbimortalidad a 30 días y a un año basado en un registro prospectivo de todos los casos de rotura de AAA admitidos de modo consecutivo (n = 32) en el servicio de urgencias de un hospital nacional de referencia durante el periodo enero del 2013 a mayo del 2015 (28 meses). El protocolo SANTIAGO es un acrónimo que describe (en lengua inglesa) 8 pasos que deben ser siempre tenidos en cuenta para una planificación EVAR: S (Size the aneurysms), A (Access), N (Neck), T (bifurcaTion), I (Iliacs), A (Angulations), G (LenGth-LonGitud) y O (OK for material). En nuestro centro, la terapia EVAR en rotura aórtica se realiza bajo anestesia local y de modo percutáneo si la situación clínica del paciente lo permite. RESULTADOS: Tras la aplicación del protocolo SANTIAGO en nuestro centro, desde junio del 2014, se consiguió reducir la mortalidad en el tratamiento urgente de aneurismas aórticos infrarrenales rotos. Fueron desestimados para ningún tipo de intervención por su elevada morbimortalidad 3 pacientes de los 32 (9,3%) admitidos en urgencias. La mortalidad total a 30 días en pacientes tratados disminuyó del 46,6% (7/15) preprotocolo frente al 35,7%(5/14) posprotocolo y en pacientes intervenidos mediante técnica endovascular pasó del 25% (1/4) preprotocolo frente a un 0%(0/6) de mortalidad posprotocolo. El 66,6% (4/6) de los pacientes tratados mediante EVAR tras el implante del protocolo fueron intervenidos de modo percutáneo y bajo anestesia local. La mortalidad al año, registrada en mayo del 2016, fue en el grupo EVAR del 10% (1/10), tasa de reintervención al año del 7,1% (1/9) por endofuga tipo ib, resuelta con éxito. En el grupo de cirugía abierta la morbimortalidad a 12 meses fue del 63,15% (12/19) de los pacientes intervenidos, con registro de un fallecimiento por IAM 7 meses postintervención y sin datos de reintervenciones mayores al año. CONCLUSIONES: Basados en la mejora de resultados observada en nuestro centro, consideramos que la existencia de un protocolo de planificación EVAR permite una planificación esquemática y reproducible que optimiza el tiempo necesario para afrontar una situación de urgencia crítica y propicia el éxito de la reparación. Asimismo, existe la tendencia progresiva en nuestro centro a considerar el tratamiento EVAR como primera opción terapéutica para pacientes con AAA-r. La posibilidad de realizar esta técnica con anestesia local y abordaje percutáneo podría ser considerada como un factor independiente que condiciona la menor morbimortalidad global del procedimiento

INTRODUCTION: Successful endovascular treatment of ruptured abdominal aortic aneurysms (R-EVAR) requires a detailed planning of the procedure, as planning is the key step. Nevertheless, in cases of emergency the limited time for planning and the non-availability of good quality scan images (DICOM format) are common issues that determine the final result. OBJECTIVE: The aim of this paper is to present the results of r-AAA survival before and after a fast protocol was implemented in our centre for measuring and sizing r-EVAR in emergency situations. METHOD: Morbidity and mortality at 30 days and 1 year was prospectively recorded in all consecutive cases of r-AAA admitted to the emergency department of our hospital (n = 32) from January 2013 to May 2015 (28 months). The «SANTIAGO planning & sizing protocol» was implemented in June 2014. It is a fast method to remember key steps in planning EVAR. With the word SANTIAGO being a mnemonic device in which 8 basic and mandatory steps in planning can be summarised: S: Size, A: Access N: Neck, T: Bifurcation I: Iliacs, A: Angulations, G: Length, O: Ok for material. R-EVAR is performed in this centre under local anaesthesia and using a percutaneous approach, if the patient tolerates it, since June 2014. RESULTS: After implementation of the SANTIAGO protocol in June 2014, the 30 day mortality was reduced from 46.6% (7/15) to 35.7% (5/14) in all patients treated in our centre for a ruptured AAA. The mortality recorded in the endovascular group was 25% (1/4) pre-protocol and 0% (0/6) after in the period analysed. A percutaneous approach and local anaesthesia was used in 66% (4/6) patients in the EVAR Group after the protocol was implemented. The 1 year mortality was 10% for all patients treated in the R-EVAR group, with a secondary intervention rate of 7.1% (1/9) due to a type Ib endoleak. In the open repair group, the 1 year morbidity/mortality was 63.15% (12/19), with a patient death at 7 months due to a myocardial infarction. CONCLUSIONS: Our first results suggest that a fast protocol for planning and sizing in emergency situations seems to be associated with a lower 30 day mortality. A higher trend for considering the patient candidate for r-EVAR has been observed in our centre. Local anaesthesia and percutaneous approach have a probable influence on the lower morbidity and mortality of the endovascular cases

Knowledge-guided mutation in classification rules for autism treatment efficacy.

Data mining methods in biomedical research might benefit by combining genetic algorithms with domain-specific knowledge. The objective of this research is to show how the evolution of treatment rules for autism might be guided. The semantic distance between two concepts in the taxonomy is measured by the number of relationships separating the concepts in the taxonomy. The hypothesis is that replacing a concept in a treatment rule will change the accuracy of the rule in direct proportion to the semantic distance between the concepts. The method uses a patient database and autism taxonomies. Treatment rules are developed with an algorithm that exploits the taxonomies. The results support the hypothesis. This research should both advance the understanding of autism data mining in particular and of knowledge-guided evolutionary search in biomedicine in general.

Controversias sobre el manejo de la fluidoterapia en cirugía abdominal / Controversies in fluid management during abdominal surgery

No disponible

Respuesta a la carta en relación con el editorial: Sabate A, Koo M. Intravenous fluids: Concepts and rationality of use. Cir Esp. 2016;94:369-371 / The authors reply: in relation to the editorial: Sabate A, Koo M. Intravenous fluids: Concepts and rationality of use. Cir Esp. 2016;94:369-371

No disponible

Resolución del conflicto intimidad de los pacientes y formación de médicos y especialistas / No disponible

No disponible

Humanización de la visita médica en pacientes ingresados en la planta de Neumología / No disponible

La atención médica a los pacientes ingresados en el hospital gira alrededor del «pase de planta». La forma de realizarlo no está estandarizada, siendo habitual hacer salir a los familiares de la habitación mientras atendemos al paciente. No disponemos de estudios que hayan valorado el impacto de realizar el pase de planta dejando a los familiares dentro de la habitación. Es por ello que nos planteamos realizar el presente estudio prospectivo, controlado, sobre humanización de la visita médica en pacientes ingresados en la planta de neumología, fundamentado en la incorporación de los familiares de los pacientes ingresados al pase de visita médica. En el periodo comprendido entre enero 2014 y diciembre 2015 fueron incluidos en el estudio 895 pacientes. Los resultados muestran que el 98% de los pacientes quieren que estén presentes su familiares (cónyuge, hijos,..) y el 100% de los familiares directos quieren estar presentes en el momento del pase de visita médica. El 95% de los pacientes quiere compartir la información médica con sus familiares en un único escenario. El grado de satisfacción de los pacientes y familiares fue muy elevado en la escala analógica-visual. La valoración del cuestionario de satisfacción mostró una elevada puntuación en todos los apartados: «comunicación médico-paciente», «relación médico-paciente» y «accesibilidad y disponibilidad». El grado de satisfacción de los profesionales fue muy elevado con este modelo de pase de visita. Además, se ha estimado un ahorro de tiempo sustancial al no tener que repetir la información a diferentes personas en distinto espacio y tiempo. Se han evitado problemas de comunicación e incertidumbres al proporcionar una información común al paciente acompañado de su familia. Han disminuido drásticamente las situaciones de conflicto entre pacientes y profesionales. Se ha reducido la variabilidad en la interpretación de la información transmitida. Por último y no menos importante, se ha generado un clima de confianza con el equipo médico que facilita la toma de decisiones por ambas partes

Medical care for patients admitted to the hospital revolves around the «daily medical visit». The way of doing this is not standardized, being common to flush out the family of the room while we take care of the patient. No studies that have assessed the impact of the daily medical visit leaving the family inside the room. That is why we plan to make this prospective controlled study on humanization of daily medical visits in patients admitted to the pulmonology plant, based on the incorporation of the relatives of patients. In the period between January 2014 and December 2015 they were included in the study 895 patients. The results have shown that 98% of patients want their family members (spouse, children, ..) are present and 100% of the relatives want to be present at the time of daily medical visit. 95% of patients want to share medical information with your family in a unique setting. The degree of satisfaction of patients and relatives was very high in the visual analog scale. The assessment of satisfaction survey showed a high score in all sections: «doctor-patient communication», «doctor-patient relationship» and «accessibility and availability». The degree of professional satisfaction was very high with this model of daily medical visit. In addition, it is estimated a substantial saving time by not having to repeat information to different people in different space and time. They have been avoided communication problems and uncertainties by providing a common patient information accompanied his family. They have drastically reduced the conflict between patients and professionals. It has been reduced variability in the interpretation of the information transmitted. Last but not least, it has generated a climate of trust with the medical team that facilitates decision-making by both parties

Capturing Provenance, Evolution and Modification of Clinical Protocols via a Heterogeneous, Semantic Social Network.

Healthcare delivery is largely based on medical best practices as in clinical protocols. Research so far has addressed the computerized execution of clinical protocols by developing a number of related representation languages, execution engines and integrated platforms to support real time execution. However, much less effort has been put into organizing clinical protocols for use and reuse. In this paper we propose a heterogeneous semantic social network to describe and organize clinical protocols based on their provenance, evolution and modifications. The proposed approach allows semantic tagging and enrichment of clinical protocols so that they can be used and re-used across platforms and also be linked directly to other relevant scientific information, e.g. published works in PubMed or personal health records, and other clinical information systems.

Plyometric type neuromuscular exercise is a treatment to postural control deficits of volleyball players: a case study / Exercícios neuromusculares do tipo pliométrico como tratamento de déficits no controle postural de jogadores de voleibol: um estudo de caso / Ejercicios neuromusculares de tipo pliométrico como tratamiento de déficits de control postural de jugadores de voleibol: a propósito de un caso

Objective. The effects of exercise protocols on postural control changes have been supported, but the influence of a common and specific type neuromuscular exercise such as plyometric on postural control is not clear. Therefore, the aim of this study was to examine the effects of plyometric type neuromuscular exercise on balance or postural control performance of young male volleyball players. Method. Ten professional young male volleyball players participated in this study and performed plyomeric exercises including 4 × 10 squat jump, broad jump, tuck jump with knee to chest, and depth jump from 45-cm box high 60 and 90 s rest between sets and exercises, respectively. Before and immediately after completing the plyometric exercise, postural control was assessed by the Star Excursion Balance Test (SEBT) at 8 directions (anterior, A; anteromedial, AM; anterolateral, AL; medial, M; lateral, L; posterior, P; posteromedial, PM; and posterolateral, PL). Results. The results indicated that plyometric exercise induced deficits in reach directions and greater changes occurred in the M, P and AL directions. Conclusions. It can be recommend that strength and conditioning professionals in the field of volleyball do not perform other type of landing exercise in plyometric training sessions because of postural control impaired and consequently the probability of lower extremity injuries will increase (AU)

Objetivo. O efeito de protocolos de exercícios sobre as mudanças no controle postural ébem conhecido, mas a influência de um tipo de treinamento neuromuscular comum e específico como o pliométrico no controle postural não está claro. O objetivo deste estudo foi examinar os efeitos dos exercícios neuromusculares do tipo pliométrico no equilíbrio e controle postural de jovens jogadores de voleibol masculino. Métodos. Dez jovens, jogadores profissionais de voleibol, participaram desse estudo e realizaram exercícios pliométricos que incluíram: 4 × 10 saltos partindo da posição de agachamento, saltos longitudinais, saltos com joelho encostando no peito e salto com rebote sob uma caixa de 40 cm de altura, com descanso entre 60-90 segundos entre as séries e exercícios, respectivamente. Antes e imediatamente após completarem o exercício de pliometria, o controle postural foi medido com as 8 direções do Star Excursion Test (SEBT) (anterior: A; antero-medial; AM; antero-lateral: AL; medial: M; lateral: L; posterior: P; póstero-medial: PM e postero-lateral: PL). Resultados. Os resultados indicam que os exercícios pliométricos induziram déficits no alcance das direções do SEBT e as maiores mudanças ocorrem nas direções M, P e AL. Conclusão. Pode ser recomendado que os profissionais que trabalham com força e condicionamento físico voltado ao voleibol não realizem outro tipo de exercício com carga nas sessões de pliometria, por causa da debilidade no controle postural que o treinamento pliométrico ocasiona e consequentemente na probabilidade de aumentar o risco de lesões nos membros inferiores (AU)

Objetivo. El efecto de protocolos de ejercicios, en cambios del control postural, son bien conocidos, pero la influencia de un sencillo y específico tipo de ejercicio neuromuscular, como los ejercicios pliométricos, en el control postural, no está clara. Por tanto, el objetivo de este estudio fue examinar los efectos de los ejercicios neuromusculares, de tipo pliométrico, en el equilibrio o en el control postural, de varones jóvenes jugadores de voleibol. Método. Diez varones jóvenes jugadores profesionales de voleibol participaron en este estudio y realizaron ejercicios pliométricos incluyendo 4 × 10 saltos con sentadilla, saltos de longitud, saltos con rodillas al pecho y saltos con rebote desde un cajón de 45 cm de altura, con 60 y 90 s de reposo entre series y ejercicios, respectivamente. Antes e inmediatamente después de completar los ejercicios pliométricos se midió el control postural mediante el Star Excursion Balance Test (SEBT) en 8 direcciones (anterior: A; anteromedial: AM; anterolateral: AL; medial: M; lateral: L; posterior: P; posteromedial: PM y posterolateral: PL). Resultados. Los resultados indican que los ejercicios pliométricos indujeron déficits en las direcciones analizadas y que los mayores cambios se produjeron en las direcciones M, P y AL. Conclusión. Se puede recomendar, a los profesionales del voleibol, en el campo del entrenamiento de la fuerza, que no realicen otros tipos de ejercicios de suelo en las sesiones de entrenamiento pliométrico, porque la disminución del control postural podría incrementar secundariamente la probabilidad de lesión del miembro inferior (AU)

Measurement of fecal elastase improves performance of newborn screening for cystic fibrosis.

BACKGROUND: The aim of newborn screening (NBS) for CF is to detect children with 'classic' CF where early treatment is possible and improves prognosis. Children with inconclusive CF diagnosis (CFSPID) should not be detected, as there is no evidence for improvement through early treatment. No algorithm in current NBS guidelines explains what to do when sweat test (ST) fails. This study compares the performance of three different algorithms for further diagnostic evaluations when first ST is unsuccessful, regarding the numbers of children detected with CF and CFSPID, and the time until a definite diagnosis. METHODS: In Switzerland, CF-NBS was introduced in January 2011 using an IRT-DNA-IRT algorithm followed by a ST. In children, in whom ST was not possible (no or insufficient sweat), 3 different protocols were applied between 2011 and 2014: in 2011, ST was repeated until it was successful (protocol A), in 2012 we proceeded directly to diagnostic DNA testing (protocol B), and 2013-2014, fecal elastase (FE) was measured in the stool, in order to determine a pancreas insufficiency needing immediate treatment (protocol C). RESULTS: The ratio CF:CFSPID was 7:1 (27/4) with protocol A, 2:1 (22/10) with protocol B, and 14:1 (54/4) with protocol C. The mean time to definite diagnosis was significantly shorter with protocol C (33days) compared to protocol A or B (42 and 40days; p=0.014 compared to A, and p=0.036 compared to B). CONCLUSIONS: The algorithm for the diagnostic part of the newborn screening used in the CF centers is important and affects the performance of a CF-NBS program with regard to the ratio CF:CFSPID and the time until definite diagnosis. Our results suggest to include FE after initial sweat test failure in the CF-NBS guidelines to keep the proportion of CFSPID low and the time until definite diagnosis short.

Reducción de ingresos y visitas a Urgencias en pacientes frágiles con insuficiencia cardíaca: resultados del programa asistencial UMIPIC / Reduction in hospitalisations and emergency department visits for frail patients with heart failure: results of the UMIPIC healthcare programme

Objetivos. La insuficiencia cardíaca (IC) es una enfermedad con una elevada morbimortalidad. Evaluamos la utilidad del programa de Unidades de Manejo Integral para Pacientes con IC (UMIPIC). Pacientes y método. Se analizaron los datos de los pacientes incluidos en el programa UMIPIC, recogidos en el registro de IC (RICA) de la Sociedad Española de Medicina Interna. Se compararon las visitas a Urgencias y las hospitalizaciones por cualquier causa y por IC durante el año anterior a la inclusión en el programa, con las que tuvieron durante el año de seguimiento posterior, usando el test de la chi-cuadrado. Resultados. Se incluyeron 258 pacientes (edad media 80 años, 51,9% mujeres). Durante el año previo hubo 693 hospitalizaciones por cualquier causa y 174 durante el seguimiento (reducción del 75%, p<0,001); 613 hospitalizaciones por IC el año antes y 92 durante el seguimiento (reducción del 85%, p<0,001); 655 vs 302 en cuanto a las visitas a Urgencias por cualquier causa (reducción del 53,9%, p<0,001); 440 vs 120 para las visitas a Urgencias por IC (reducción del 72%, p<0,001). No hubo diferencias significativas en el número de hospitalizaciones o visitas a Urgencias por otras causas diferentes a la IC. Conclusiones. El programa UMIPIC basado en la atención integral a pacientes ancianos con IC y comorbilidad reduce el porcentaje de reingresos hospitalarios y visitas a Urgencias durante el primer año de seguimiento (AU)

Objectives. Heart failure (HF) is a disease with high morbidity and mortality. We evaluated the usefulness of the Comprehensive Management Units for Patients with HF (Unidades de Manejo Integral para Pacientes con IC [UMIPIC]) programme. Patients and method. We analysed the patient data from the UMIPIC programme, which was recorded in the HF registry (RICA) of the Spanish Society of Internal Medicine. We compared emergency department visits and hospitalisations for any cause and for HF during the year prior to inclusion in the programme against those that occurred during the subsequent follow-up year, using the chi-squared test. Results. A total of 258 patients (mean age, 80years; 51.9% women) were included in the study. During the previous year, there were 693 hospitalisations for all causes and 174 hospitalisations during the follow-up (75% reduction, P<.001). There were 613 hospitalisations for HF during the previous year and 92 during the follow-up (85% reduction, P<.001); 655 vs. 302 in terms of emergency department visits for any cause (53.9% reduction, P<.001); and 440 vs. 120 for emergency department visits for HF (72% reduction, P<.001). There were no significant differences in the number of hospitalisations or emergency department visits for causes other than HF. Conclusions. The UMIPIC programme based on the comprehensive care of elderly patients with HF and comorbidity reduces the rate of hospital readmissions and emergency department visits during the first year of follow-up (AU)

Asistencia compartida (comanagement) / Shared care (comanagement)

Los servicios quirúrgicos tienen dificultades crecientes en la atención a sus pacientes ingresados debido a la mayor edad y comorbilidad, a una formación médica en creciente especialización y a la fuerte presión político-sanitaria que impone una organización asistencial donde prima el acto quirúrgico frente a las demás actividades. La presión que ejercen estos servicios sobre el área médica y la respuesta deficiente ofrecida por el sistema de interconsulta han provocado el desarrollo de un modelo diferente de organización asistencial: la asistencia compartida, la cual incluye la medicina perioperatoria. En ella 2 especialistas diferentes comparten la responsabilidad y autoridad en la atención de un paciente quirúrgico ingresado. Medicina Interna es la especialidad más adecuada para la asistencia compartida. El internista que la ejerza ha de tener unas características determinadas y debe superar una serie de temores del cirujano y del anestesista (AU)

Surgical departments have increasing difficulties in caring for their hospitalised patients due to the patients’ advanced age and comorbidity, the growing specialisation in medical training and the strong political-healthcare pressure that a healthcare organisation places on them, where surgical acts take precedence over other activities. The pressure exerted by these departments on the medical area and the deficient response by the interconsultation system have led to the development of a different healthcare organisation model: Shared care, which includes perioperative medicine. In this model, 2 different specialists share the responsibility and authority in caring for hospitalised surgical patients. Internal Medicine is the most appropriate specialty for shared care. Internists who exercise this responsibility should have certain characteristics and must overcome a number of concerns from the surgeon and anaesthesiologist (AU)

Acute kidney stress--a useful term based on evolution in the understanding of acute kidney injury.

Critical care physicians have debated an appropriate term for the clinical phase preceding acute kidney injury (AKI). The recent development of cell cycle arrest biomarkers that signal the potential development of AKI is part of an evolution in the molecular diagnosis and understanding of AKI. It is proposed that the pre-injury phase that leads to AKI can be described as "acute kidney stress". This term has the potential to expand horizons in regard to the early detection of situations that will lead to AKI and the early implementation of corrective measures.

Prospective study of cyclophosphamide, thiotepa, carboplatin combined with adoptive DC-CIK followed by metronomic cyclophosphamide therapy as salvage treatment for triple negative metastatic breast cancers patients (aged <45)

Background. The recent immunotherapy treatment on triple-negative breast cancer (TNBC) leads to the breakthrough assignation. In this study, we have tried the new combinations of specific chemo with DC-CIKs immunotherapy to treat those patients. Patients and methods. Twenty-three metastatic anthracyclines and taxanes pretreated TNBC younger (mean 41.5 years) patients were initially mobilized with cyclophosphamide (3 g/m2) for the preparation of CD34+ peripheral blood mononuclear cells as the resources for generating DC/CIKs and marrow function supports. All cases were subsequently experienced 2 cycles of chemotherapy with cyclophosphamide 3 g/m2, thiotepa 150 mg/m2, and carboplatin AUC = 6, Q4w. The patients then received 3 infusions of DC-CIKs at the chemo intervals and followed by maintenance therapy with oral cyclophosphamide 50 mg daily. The endpoints were progression-free survival and overall survival. Results. The partial response rate was 13.0 %, stable and progressive disease rates were 56.5 and 30.4 %, respectively. The median PFS was 13.5 months (95 % confidence interval (CI) 10.1-16.9 months) and OS was 15.2 months (95 % CI 12.5-18.1 months). The most common serious adverse events were neutropenia (100.0 %) and anemia (69.7 %) but without treatment-related mortality. Conclusion. These data suggested that such combination therapy model be effective and safe for younger metastatic TNBC exposure to previous anthracyclines and taxanes based adjuvant chemotherapy (AU)

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An evaluation of different steam disinfection protocols for cystic fibrosis nebulizers.

BACKGROUND: Contamination is a key element in cystic fibrosis. For this reason, nebulizer hygiene is an important, but complex and time-consuming task for cystic fibrosis patients. The aim of this study was to compare different steam disinfection and drying protocols. METHODS: One hundred nebulizer parts were inoculated with cystic fibrosis-related bacteria in high concentrations (Burkholderia multivorans 3.9 × 10(10)/ml, Staphylococcus aureus 8.9 × 10(8/)ml and Pseudomonas aeruginosa 2.1 × 10(9)/ml). Tubes with Mycobacterium abscessus complex were additionally tested. Six steam disinfectors were compared. Different methods of drying were examined. RESULTS: All tested bacteria were efficiently killed by the different steam disinfectors tested. The risk of contamination depended on the method of drying. CONCLUSIONS: Steam disinfection is a safe disinfection method. It is better to leave the nebulizers wet after steam disinfection than to manipulate them by active drying, which seems to be a source of recontamination.