Impact of the implementation of a Sepsis Code Program in medical patient management: a cohort study in an Internal Medicine ward.

OBJECTIVE: Sepsis is the main cause of death in hospitals and the implementation of diagnosis and treatment bundles has shown to improve its evolution. However, there is a lack of evidence about patients attended in conventional units. METHODS: A 3-year retrospective cohort study was conducted. Patients hospitalized in Internal Medicine units with sepsis were included and assigned to two cohorts according to Sepsis Code (SC) activation (group A) or not (B). Baseline and evolution variables were collected. RESULTS: A total of 653 patients were included. In 296 cases SC was activated. Mean age was 81.43 years, median Charlson comorbidity index (CCI) was 2 and 63.25% showed some functional disability. More bundles were completed in group A: blood cultures 95.2% vs 72.5% (p <0.001), extended spectrum antibiotics 59.1% vs 41.4% (p < 0.001), fluid resuscitation 96.62% vs 80.95% (p < 0.001). Infection control at 72 hours was quite higher in group A (81.42% vs 55.18%, odds ratio 3.55 [2.48-5.09]). Antibiotic was optimized more frequently in group A (60.77% vs 47.03%, p 0.008). Mean in-hospital stay was 10.63 days (11.44 vs 8.53 days, p < 0.001). Complications during hospitalization appeared in 51.76% of patients, especially in group B (45.95% vs 56.58%, odds ratio 1.53 [1.12-2.09]). Hospital readmissions were higher in group A (40% vs 24.76%, p < 0.001). 28-day mortality was significantly lower in group A (20.95% vs 42.86%, odds ratio 0.33 [0.23-0.47]). CONCLUSIONS: Implementation of SC seems to be effective in improving short-term outcomes in IM patients, although therapy should be tailored in an individual basis.

Will borealization of Arctic tundra herbivore communities be driven by climate warming or vegetation change?

Poleward shifts in species distributions are expected and frequently observed with a warming climate. In Arctic ecosystems, the strong warming trends are associated with increasing greenness and shrubification. Vertebrate herbivores have the potential to limit greening and shrub advance and expansion on the tundra, posing the question of whether changes in herbivore communities could partly mediate the impacts of climate warming on Arctic tundra. Therefore, future changes in the herbivore community in the Arctic tundra will depend on whether the community tracks the changing climates directly (i.e. occurs in response to temperature) or indirectly, in response to vegetation changes (which can be modified by trophic interactions). In this study, we used biogeographic and remotely sensed data to quantify spatial variation in vertebrate herbivore communities across the boreal forest and Arctic tundra biomes. We then tested whether present-day herbivore community structure is determined primarily by temperature or vegetation. We demonstrate that vertebrate herbivore communities are significantly more diverse in the boreal forest than in the Arctic tundra in terms of species richness, phylogenetic diversity and functional diversity. A clear shift in community structure was observed at the biome boundary, with stronger northward declines in diversity in the Arctic tundra. Interestingly, important functional traits characterizing the role of herbivores in limiting tundra vegetation change, such as body mass and woody plant feeding, did not show threshold changes across the biome boundary. Temperature was a more important determinant of herbivore community structure across these biomes than vegetation productivity or woody plant cover. Thus, our study does not support the premise that herbivore-driven limitation of Arctic tundra shrubification or greening would limit herbivore community change in the tundra. Instead, borealization of tundra herbivore communities is likely to result from the direct effect of climate warming.

2019 IUSTI-Europe guideline for the management of anogenital warts.

This guideline is an update of the 2011 European Guideline for the Management of Anogenital Warts. It is intended to support best practice in the care of patients with anogenital warts by including evidence-based recommendations on diagnosis, treatment, follow-up and advice to patients. It is intended for use by healthcare professionals in sexual healthcare or dermato-venereology clinics in Europe but may be adapted for use in other settings where the management of anogenital warts is undertaken. As a European guideline, recommendations should be adapted according to national circumstances and healthcare systems. Despite the availability of vaccine to prevent HPV types 6 and 11, the cause of >95% anogenital warts, they remain an important and frequent health problem. The previous systematic review of randomized controlled trials for anogenital warts was updated. The changes in the present guideline include the following: Updated background information on the prevalence, natural history and transmission of human papillomavirus (HPV) infection and anogenital warts. Key recommendations for diagnosis and treatment have been graded according to the strength of the recommendation and the quality of supporting evidence. 5-fluorouracil, local interferon and photodynamic therapy have been evaluated and included as potential second-line treatment options. Evidence of the impact of HPV vaccination on the incidence of anogenital warts has been updated.

Actividades deportivas con soporte musical: ¿una nueva forma de aprender reanimación cardiopulmonar? / Sports Activities with Musical Support: A New Way to Learn Cardiopulmonary Resuscitation?

El objetivo del estudio fue analizar la viabilidad de enseñar RCP en actividades deportivas con apoyo musical y evaluar si este nuevo enfoque iguala los resultados de un curso tradicional de reanimación cardiopulmonar (RCP). Participaron 84 estudiantes universitarias sin conocimientos de RCP distribuidas en dos grupos de forma aleatoria. El primero recibió formación de RCP sólo manos integradas en una clase de aeróbic y el otro recibió un curso de RCP de manera convencional. Los resultados en la clase coreografiada comparados con el curso tradicional fueron: Profundidad media de compresiones (41,64 vs 42,92; p = 0,446), re-expansión correcta (65,47% vs 72,47%; p = 0,423), frecuencia de compresiones en un minuto (102,50 vs 138,53; p < 0,001), compresiones totales (202,50 vs 277,95; p < 0,001). Los dos métodos formativos alcanzaron resultados similares por lo que la introducción de la enseñanza de RCP en actividades deportivas puede ser un nuevo método formativo

The aim of the study was to analyse the feasibility of teaching CPR in sports activities with musical support in order to assess if this new methodology of CPR training is as effective as a traditional CPR course. 84 university students with no knowledge of CPR participated. They were distributed in two groups randomly. The first one received an experimental fitness dance class CPR course and the other was given a traditional training CPR course. The following parameters were obtained: fitness dance class group vs traditional CPR course: Average compression depth (41,64 vs 42,92; p = 0,446), Chest Recoil (65,47% vs 72,47%; p = 0,423), average compression rate (102.50 vs 138.53; p<0.001), total number of compressions (202.50 vs 277.95; p< 0.001). The two training methods achieved similar results, so CPR teaching in sports activities with musical support can be a new training method

Epidemiology, molecular characterisation and antimicrobial susceptibility of Neisseria gonorrhoeae isolates in Madrid, Spain, in 2016.

With the aim to elucidate gonococcal antimicrobial resistance (AMR)-risk factors, we undertook a retrospective analysis of the molecular epidemiology and AMR of 104 Neisseria gonorrhoeae isolates from clinical samples (urethra, rectum, pharynx and cervix) of 94 individuals attending a sexually transmitted infection clinic in Madrid (Spain) from July to October 2016, and explored potential links with socio-demographic, behavioural and clinical factors of patients. Antimicrobial susceptibility was determined by E-tests, and isolates were characterised by N. gonorrhoeae multi-antigen sequence typing. Penicillin resistance was recorded for 15.4% of isolates, and most were susceptible to tetracycline, cefixime and azithromycin; a high incidence of ciprofloxacin resistance (~40%) was found. Isolates were grouped into 51 different sequence types (STs) and 10 genogroups (G), with G2400, ST5441, ST2318, ST12547 and G2992 being the most prevalent. A significant association (P = 0.015) was evident between HIV-positive MSM individuals and having a ciprofloxacin-resistant strain. Likewise, a strong association (P = 0.047) was found between patient age of MSM and carriage of isolates expressing decreased susceptibility to azithromycin. A decrease in the incidence of AMR gonococcal strains and a change in the strain populations previously reported from other parts of Spain were observed. Of note, the prevalent multi-drug resistant genogroup G1407 was represented by only three strains in our study, while the pan-susceptible clones such as ST5441, and ST2318, associated with extragenital body sites were the most prevalent.

Valoración inicial del paciente adulto con condilomas acuminados / Initial evaluation of the adult patient with condylomata acuminata

No disponible

A randomized trial to assess the efficacy of a psychoeducational intervention on caregiver burden in schizophrenia.

BACKGROUND: Patient's relatives usually care for patients with schizophrenia, and as informal caregivers they experience negative consequences. The aim of the EDUCA-III trial is to test the efficacy of a psychoeducational intervention program (PIP) versus standard care to reduce the caregiver burden at post-intervention (4 months), and at follow-up (8 months). METHOD: A two-arm, evaluator blind, multicentre, randomized controlled trial. The PIP group had 12 weekly group sessions. The control intervention group had the usual support and standard care. Primary outcomes were change scores since baseline on the Zarit Burden Interview (ZBI) and the Involvement Evaluation Questionnaire (IEQ). RESULTS: One hundred and nine caregivers were randomized to PIP and 114 to control condition from 23 research sites. The decrease of ZBI scores was significantly higher on the PIP arm at 4 months (mean difference [MD]=-4.33; 95% CI -7.96, -0.71), and at 8 months (MD=-4.46; 95% CI -7.79, -1.13). There were no significant decreases in the IEQ scores (MD at 4 months=-2.80; 95% CI -6.27, 0.67; MD at 8 months=-2.85; 95% CI -6.51, 0.81). CONCLUSIONS: The PIP condition seems to reduce caregiver burden. TRIAL REGISTRATION: ISRCTN32545295.

Individualised dosimetry in patients with differentiated thyroid cancer based on external dose-rate. Optimisation of the number of measurements.

OBJECTIVES: To compare the results of individual dosimetry in differentiated thyroid cancer patients treated with (131)I at our centre with the established limits and dosimetry results of published studies. Analysis of the optimal number of measurements necessary to reduce the impact of dosimetry for the comfort of the patient and, secondly, on the workload of health workers. MATERIAL AND METHODS: Dosimetry was performed in the Nuclear Medicine Department of the University and Polytechnic Hospital La Fe, on 29 patients suffering from differentiated thyroid cancer and treated with activities between 1.02 and 5.51 GBq (mean 2.68 GBq) of (131)I. The Spanish Society of Medical Physics (SEFM) protocol was used, based on measurements of external dose rate adjusted to a bi-exponential curve according to a two compartment model. Different dosimetries were performed on each patient, taking different selections of the available measurements in order to find the optimal number. RESULTS: Results are well below the dosimetry limits, and are consistent with those obtained in other centres. The number of measurements can be reduced from 5, as proposed in the SEFM protocol, to 4 without significant loss of accuracy. Further reducing measures may be justified in individual cases. CONCLUSIONS: The values obtained for the dosimetry quantities are significantly below the established limits. A reduction in measurements can be assumed at the cost of a moderate increase in uncertainty, benefiting the patient.

Inflammation-induced hyperalgesia and spinal microglia reactivity in neonatal rats.

BACKGROUND: Peripheral inflammation and nerve injury evoke pain behaviours in adult rodents mediated by sensitization, a process that involves the activation of microglia in the spinal cord. In neonates, however, peripheral inflammation, but not nerve injury, induces a lasting hyperalgesia. It is known that microglia does not activate after nerve injury in young pups; however, changes in microglia associated with inflammation in neonatal animals have not been studied. METHODS: Inflammation was induced by unilateral intraplantar injection of carrageenan, complete Freund's adjuvant or zymosan in 10-day-old rats. Rats were tested for mechanical sensitivity in response to punctuate stimulation of the dorsal surface of the hind paw using calibrated von Frey filaments. Immunohistochemistry was used to detect changes in size and density of microglial cells using the specific marker Iba-1. The effects of minocycline applications (120 µg, i.t.) on spinal microglia and behaviour induced by zymosan inflammation were studied. RESULTS: Hind paw inflammation in young P10 rats, with either of the agents used, produced an immediate hyperalgesia, which lasted more than 7 days. A concomitant and significant increase in cell size and density in Iba-1-positive cells was observed in the spinal dorsal horn. These morphological changes in spinal microglia were observed as early as 1-h post-inflammation. Intrathecal and systemic administration of minocycline blocked the hyperalgesia and the changes in spinal microglia produced by zymosan. CONCLUSIONS: Results suggest a key role for spinal microglia activation in the development of hyperalgesia following inflammation in neonatal animals.

Invasive device-related infections after heart surgery.

OBJECTIVE: To analyze postoperative infections in critically ill patients undergoing heart surgery. SETTING: Intensive care units (ICUs). DESIGN: An observational, prospective, multicenter study was carried out. PATIENTS: Patients in the postoperative period of heart surgery admitted to the ICU and included in the ENVIN-HELICS registry between 2005 and 2011. MAIN OUTCOME VARIABLES: Mechanical ventilation associated pneumonia (MVP), urinary catheter-related infection (UCI), primary bacteremia (PB), PB related to vascular catheters (PB-VC) and secondary bacteremia. RESULTS: Of a total of 97,692 patients included in the study, 9089 (9.3%) had undergone heart surgery. In 440 patients (4.8%), one or more infections were recorded. Infection rates were 9.94 episodes of MVP per 1000 days of mechanical ventilation, 3.4 episodes of UCI per 1000 days of urinary catheterization, 3.10 episodes of BP-VC per 1000 days of central venous catheter, and 1.84 episodes of secondary bacteremia per 1000 days of ICU stay. Statistically significant risk factors for infection were ICU stay (odds ratio [OR] 1.18, 95%CI 1.16-1.20), APACHE II upon admission to the ICU (OR 1.05, 95%CI 1.03-1.07), emergency surgery (OR 1.67, 95%CI 1.13-2.47), previous antibiotic treatment (OR 1.38, 95%CI 1.04-1.83), and previous colonization by Pseudomonas aeruginosa (OR 18.25, 95%CI 3.74-89.06) or extended spectrum beta-lactamase producing enterobacteria (OR 16.97, 95%CI 5.4-53.2). The overall ICU mortality rate was 4.1% (32.2% in patients who developed one or more infections and 2.9% in uninfected patients) (P < .001). CONCLUSIONS: Of the patients included in the ENVIN-HELICS registry, 9.3% were postoperative heart surgery patients. The overall mortality was low but increased significantly in patients who developed one or more infection episodes.

A systematic review and meta-analysis of MTHFR polymorphisms in methotrexate toxicity prediction in pediatric acute lymphoblastic leukemia.

Methotrexate (MTX) is an important component of therapy used to treat childhood acute lymphoblastic leukemia (ALL). Two single-nucleotide polymorphisms (SNPs) in the methylenetetrahydrofolate reductase (MTHFR) gene, C677T and A1298C, affect MTHFR activity. A large body of studies has investigated the potential role of MTHFR SNPs in MTX toxicity in pediatric ALL. However, the results are controversial. In this review and meta-analysis, we critically evaluate the relationship between the C677T and A1298C polymorphisms of MTHFR and MTX toxicity in pediatric ALL. The majority of published reports do not find associations between MTHFR polymorphisms and toxicity in pediatric ALL. When associations are reported, often the results are contradictory to each other. The meta-analysis confirms a lack of association. In conclusion, MTHFR, C677T and A1298C polymorphisms do not seem to be good markers of MTX-related toxicity in pediatric ALL.

Treatment of AO Type C Fractures of the Distal Part of the Humerus through the Bryan-Morrey Triceps-Sparing Approach.

Several alternative approaches have been described to avoid the complications related to the olecranon osteotomy used to treat distal articular humerus fractures. The published experience with the triceps-sparing approach is scant. In this prospective study, a total of 12 patients with an articular humeral fracture were treated using this approach. At a mean followup of 1,7 years, the average range of motion was 112.8° (range from 85° to 135°); the elbow flexion averaged 125.5° (range from 112° to 135°) and the deficit of elbow extension 14.6° (range from 0° to 30°). All the elbows were stable. The Mayo Elbow Performance Score (MEPS) averaged 93.3 (range from 80 to 100). In the present series no failure of the triceps reattachment to the olecranon was found, and all the patients recalled returning to their previous daily life activities without impairment with a satisfactory MEPS. As a conclusion, the triceps-sparing approach can be considered for treating distal articular humerus fractures. We consider that three clinical settings can be more favorable to use this approach: those cases in which a total elbow prosthesis might be needed, cases of ipsilateral diaphyseal fracture, or presence of previous hardware in the olecranon.

Evaluation of biological specimen acceptability in a complex clinical laboratory before and after implementing automated grading serum indices.

Continuous monitoring of specimen acceptability, collection and transport can result in the prompt identification and correction of problems, leading to improved patient care and a reduction in unnecessary redraws and delays in reporting results. This study aims to identify unacceptable blood specimens and to calculate the specimen rejection rate (SRR) before and after the implementation of automated checks of serum indices. This study was conducted between January 2009 and December 2010. The number of rejected specimens, location and reason for rejection were recorded. The Architect c8000 analyser (Abbott, Illinois, USA) was used to assess serum indices based on characteristic spectral patterns and mathematical manipulations of absorbance values measured at several wavelengths. The SRR was calculated, and the target cut-off value for the SRR was < 0.5%, as established by the College of American Pathologists (CAP). The SRR values were 0.13% and 0.21% for the years 2009 and 2010, respectively. Haemolysis was the most significant reason for sample rejection, with cumulative rejection rates (CRR) of 49.3% and 61.4% for 2009 and 2010, respectively. Adult intensive care units (ICUs) had the most sample rejections (23.5%), followed by neonatal ICUs (13.8%), cardiac ICUs (13%), paediatric ICUs (10.8%) and long-term wards (10.5%), of which 60%, 79%, 84.9%, 36.6% and 75%, respectively, of the rejected samples were haemolysed. The increase in rejected samples may be due to an improvement in staff awareness of sample rejection, aided by automatic sample integrity grading by automated chemistry analysis systems.

Análisis factoriales confirmatorios de la escala de sobrecarga de zarit / No disponible

Introducción. La escala de sobrecarga de Zarit (ZBi) se utiliza para evaluar la sobrecarga que experimentan los cuidadores informales de personas con discapacidades o dependencias. como escala acumulativa, la ZBi debería evaluar el constructo latente de sobrecarga desde una perspectiva unidimensional. Sin embargo, diferentes análisis factoriales han indicado que presenta una estructura multidimensional, lo que puede ser importante para una correcta interpretación de la escala. Objetivos. Analizar y comparar el ajuste de las diferentes estructuras factoriales propuestas para la ZBi mediante Análisis Factorial confirmatorio (..) (AU)

Introduction. The Zarit Burden interview (ZBi) is usually applied to assess the burden experienced by caregivers of persons with severe functional limitations. As a measurement scale giving a total score, the ZBi implicitly assumes that the latent construct it measures is unidimensional. However several factorial analyses of the ZBi have reported instead a multidimensional structure, what can be relevant for a correct interpretation. Aims. to analyze and to compare the fit of the factorial structures so far reported for the ZBi by using confirmatory factor analyses (cFA) applied to (..) (AU)