Procesos más frecuentes y perfil clínico de los pacientes atendidos en un Servicio de Rehabilitación / Most Frequent conditions and clinical profile of the patients seen in a rehabilitation service

Introducción: Múltiples trabajos evidencian que la Rehabilitación mejora la calidad de vida del paciente. Nuestro objetivo es conocer el perfil clínico de los pacientes atendidos en nuestro Servicio de Rehabilitación y Medicina Física. Pacientes y Métodos: Es un estudio prospectivo, en el que se recogen los procesos de pacientes atendidos entre el 1-1-1993 y el 1-1-1999, y se analizan los datos más significativos. Resultados: Se ha dado de alta a un total de 8.380 pacientes, de los que 3.150 (37,6 por ciento) eran hombres y 5.230 (62,4 por ciento) eran mujeres. Su edad media era de 51,8ñ21,6 años. El grupo de procesos más frecuente fue el de algias de raquis en 1.430 (17,06 por ciento). El intervalo primera visita / prescripción de tratamiento fisioterápico fue de 3,1ñ26 días. El intervalo prescripción / inicio de tratamiento fue de 20,5ñ38,9 días. La duración del tratamiento fue de 42,5ñ372 días. El intervalo fin de tratamiento / alta médica fue de 18,5 ñ 402 días. La duración del proceso fue de 95,39ñ308 días. Predominó la procedencia de los pacientes del propio Hospital en 4.383 (52,3 por ciento) y del Servicio de Cirugía Ortopédica y Traumatología en 4.886 (58,3 por ciento). El número medio de consultas por proceso fue de 2,26ñ0,52. La situación clínica de curación o mejoría al alta fue la más frecuente en 6.711 (80,08 por ciento). Predominaba el transporte particular en 5.511 (65,76 por ciento). La técnica de tratamiento más utilizada fue la cinesiterapia en 6.323 (75,45 por ciento), con una media de 18,63 sesiones. La prueba más solicitada fue la RX en 2.586 (30,85 por ciento). La ortesis más prescrita fue el andador en 475 (5,66 por ciento). El coste medio por proceso fue de 49.252,03 pesetas. Discusión: La discapacidad funcional es común en los pacientes atendidos y son múltiples los protocolos que tratan de valorarla, analizar sus tratamientos potenciales y calcular su coste. Conclusiones: El paciente dado de alta en este Servicio es predominantemente mujer, de 51,8 años de edad, procede del Servicio de Cirugía Ortopédica y Traumatología del propio hospital, es tratada mediante técnicas de cinesiterapia, mecanoterapia y termoterapia. El grupo de procesos más frecuente es el de algias de raquis y el proceso más frecuente la fractura de cadera. La duración media del proceso es de 95,39 días. Las ayudas más utilizadas son las de la deambulación y predomina el transporte particular. La mejora clínica se produce en el 80,08 por ciento de los casos. El coste medio por proceso rehabilitador es de 49.252,03 ptas. (AU)

[Vancomycin and teicoplanin use as antibiotic prophylaxis in cardiac surgery: pharmacoeconomic study]. / Vancomicina y teicoplanina como profilaxis antibiótica en cirugía cardíaca: estudio farmacoeconómico.

BACKGROUND: To assess the economical impact of vancomycin use versus teicoplanin use as antibiotic prophylaxis for patients undergoing cardiac surgery for valve replacement (VR) and coronary artery by-pass (CABS) procedures. PATIENTS AND METHODS: This is an ancillary cost minimization analysis of a double blinded, parallel groups, randomised clinical trial (RCT), with the main objective of comparing the safety and efficacy of these antibiotics. 500 patients were included in the study; 267 in the CABS group and 233 in the VR group. The CABS patients received 1 g vancomicin or 400 mg teicoplanin, plus 150 mg netilmicin. The VR group received a second dose of each drug after extracorporeal circulation. In order to calculate the costs we considered the direct cost of the drug, the i.v. mix and the administration costs, together with personnel and structure costs. We considered two different situations: the administration of drugs within the surgical room theatre and in the medical ward. RESULTS: The demographic data of both groups were comparable. The frequency of severe adverse drug reactions (ADR) were similar (0.4%) in both groups, as well as the post-operative infection rates (8.6%). Differences were seen in the frequencies of low severity ADRs: 20.4% in the vancomycin group and 1.6% in the teicoplanin group. When the antibiotics were administered in the surgical room, among CABS patients the costs were 8,265 pts. for the teicoplanin group and 12,005 pts. for the vancomycin group; while among VR patients, costs were respectively 11,661 pts. and 14,528 pts. Administration costs of teicoplanin and vancomycin within a medical ward setting, however, the costs were 6,740 pts. and 2,809 pts. for CABS patients, and 5,308 pts. and 10,140 pts. for VR patients, respectively. CONCLUSIONS: The costs of antibiotic prophylaxis among cardiac surgery patients heavily depends on the setting and circumstances of drug administration. The minimization cost analysis indicates that teicoplanin is the most cost-effective option if the drug is administered within the surgical area, while vancomycin is the less costly option when administered within the medical ward. However, if the second option is to be chosen, it is necessary to assure the right plasmatic drug levels of the antibiotic at the beginning of the surgical procedure.

[Pneumocystis carinii pneumonia in the transplant recipient]. / Neumonía por Pneumocystis carinii en el receptor de trasplante.

BACKGROUND: The aim of the present was to study the clinical characteristics and prognostic factors of 20 cases of pneumonia by Pneumocystis carinii (NPC) diagnosed over the last 10 years in renal, renopancreatic, liver and bone marrow transplant recipients. METHODS: The clinical histories of all the patients transplanted in the authors' hospital from 1985 to 1994 who developed NPC were analyzed. Diagnosis was established by visualization of cysts in methenamine silver staining of bronchialveolar lavage (BAL) samples. RESULTS: The global incidence of NPC in our transplant population was 1%. However, the incidence was 3% in the recipients who did not receive prophylaxis. No patient in this series received prophylaxis at the time of diagnosis. Ninety percent of the patients had history or rejection. Pneumonia was observed in 15 (75%) in the first 6 months post transplantation. The mean length of the symptoms prior to diagnosis was 10 days. Ninety-five percent of the patients presented cough, dysnea and fever. Radiology demonstrated diffuse alveolointerstitial infiltrates in 18 patients (90%). Basal arterial PO2 was lower than 60 mmHg in 14 (70%) patients and the alveoloarterial gradient of oxygen was greater than 60 mmHg in 9 (45%). Mechanical ventilation was required in 50% of the patients. BAL demonstrated cytologic alterations compatible with CMV infection in 50% of the cases and in two Aspergillus fumigatus was associated. Mortality was 35%. The only variable significantly associated with bad prognosis was the need for mechanical ventilation (p = 0.003). CONCLUSIONS: The incidence of pneumonia by P. carinii in a population of transplant recipients was 1%. No patient received primary prophylaxis at the time of diagnosis. Most of the episodes were observed during the first 6 months post transplant. Mortality was 35% with the only variable with prognostic significance being the need for mechanical ventilation.

[138 episodes of bacteremia or fungemia in patients with solid organ (renal or hepatic) transplantation]. / Estudio de 138 episodios de bacteriemia o funguemia en pacientes con trasplante de órgano sólido (renal o hepático).

BACKGROUND: To study the bacteremias and fungemias of the patients with solid organ transplantation (kidney or liver) and analyze the differences according to the type of graft. METHODS: A prospective study included in a control program of bacteremias of a 1000-bed hospital and a follow up study of the infections of the patients who had undergone kidney transplantation (KT) (1985-1991) and liver transplantation (LT) (1988-1991) were carried out. RESULTS: One hundred thirty-one bacteremias and 5 fungemias, 75 in 62 patients with KT out of a total of 568 transplantations (11%) and 63 out of 54 patients with LT out of a total of 185 transplantations (29%) were identified. The prevalence of bacteremia in LT was greater (p < 0.001). The origin was nosocomial in 95% in LT and 70% in KT (p < 0.001). Around 50% of the bacteremias occurred during the first month post LT and KT. The microorganisms isolated were: Staphylococcus sp. (21 in KT and 30 in LT), with greater incidence in LT (p < 0.05); Enterococcus sp. (9 and 5, respectively), enterobacterias (12 and 12, respectively), Pseudomonas sp. (14 and 6, respectively), Candida sp. (2 and 3, respectively) with similar rates in both transplants. The origin of bacteremia was; renal and urinary tract, most frequent in KT (21 and 2 respectively) (p = 0.001). The origin of bacteremia was: renal and urinary tract, most frequent in KT (21 and 2 respectively) (p < 0.001), intraabdominal and biliary tract, most frequent in LT (4 and 14, respectively) (p = 0.007); intravenous catheter, most frequent in LT (16 and 24 respectively) (p < 0.05); lung, most frequent in LT although without statistical significance (3 and 8, respectively), (p = NS), and finally, surgical wound (4 and 1, respectively) (p = NS). Seventeen patients died (14 with LT and 3 with KT). CONCLUSIONS: The incidence of bacteremia and the mortality related, was greater in LT than that observed in KT. The most frequent origin in KT was the kidney and urinary tract and the biliary and intraabdominal organs and the intravenous catheter were most prevalent in liver transplants. Staphylococcus sp was the most frequent germ in both types of transplantation and polymicrobian infection in liver transplants. Gram-negative germs caused higher mortality in liver transplantation.

[Acute gastroenteritis: a prospective study of 445 cases]. / Gastroenteritis aguda: estudio prospectivo de 445 casos.

Four hundred and fourty-five adult patients suffering acute gastroenteritis (AG) seen at the emergency ward of two hospitals in Barcelona, have been studied. The aim of this work was to analyze the cause of AG in our community and to evaluate the utility of the biologic and clinical criteria chosen as indicators of bacteremia or of AG produced by invasive microorganisms. Stool culture was positive in 157 patients (35%) of which 140 were Salmonella sp. The most frequently isolated serotype was S. enteritidis. Eight patients (7.8%) presented Salmonella sp. bacteremia. Presence of an underlying disease, dehydration, shivers, fever, presence of occult blood in stools, septic hemogram and the history of AG in other family members were more common in patients with a positive stool culture (p less than 0.05). Patients with bacteremia presented dehydration with a significantly higher frequency than nonbacteremics. The rest of the parameters studied were similar in both groups. We conclude that Salmonella sp. is the most frequently encountered microorganisms responsible for adult AG in our community. It is possible to identify patients with AG due to Salmonella sp. based on clinical and biological parameters. On the contrary, it is necessary to perform a wider study in order to determine the parameters that may allow the identification of patients with bacteremia.