Validación de las escalas de Braden y EMINA en pacientes de atención domiciliaria incluidos en programa de inmovilizados / Validity of Braden and EMINA’s scales for patients at home, include in the immobilized patients programmee

Objetivo: comprobar la validez de las escalas Braden y EMINA y seleccionar puntos de corte cuantitativos para discriminar el riesgo de úlcera por presión (UPP) en pacientes domiciliarios. Método: estudio longitudinal o de seguimiento de una cohorte de 6 meses de duración, con cuatro valoraciones, una cada 2 meses. Ámbito de estudio: áreas de gestión sanitaria Este de Málaga-Axarquía y Serranía, de Málaga. Sujetos de estudio: pacientes en programa de inmovilizados sin UPP. Cuestionario confeccionado por los autores que incluye entre otros: datos demográficos, ingreso hospitalario, escalas de Braden y EMINA. Muestra: 353 pacientes, usando muestreo aleatorio simple. Resultado: las escalas originales mantienen consistencia interna con alpha superior a 0,7. Se han establecido nuevos puntos de corte, discriminando pacientes con riesgo de UPP o sin él, resultando una sensibilidad del 61-89% y una especificidad del 64-70%. Las escalas categorizadas tienen exactitud como método diagnóstico igual o superior al 65%. Las odds ratio (OR) son significativas e indican que existen diferencias en el riesgo de UPP en función de nuevos puntos de corte. La determinación de los puntos de corte resultaron: riesgo alto: sensibilidad ≤ 10%, especificidad ≥ 95%, puntuación en la escala de Braden ≤ 10, EMINA 12-15; riesgo moderado: sensibilidad entre el 10% y el 83%, especificidad entre el 64% y el 95%, Braden 11-15 y EMINA 7-11; riesgo bajo: sensibilidad entre el 83% y el 100%, especificidad entre el 0% y el 64%, Braden 16-22 y EMINA 1-6; riesgo nulo: sensibilidad 100%, especificidad 0%, Braden 23, EMINA 0

Aim: Verifying Braden and EMINA's validity and select quantitative cut-off points to differentiate Ulcer by Pressure threat in home-care patients. Method: group monitor progress and longitudinal examination of a cohort of patients during 6 months, evaluating three times, once every two months. Scope of application: Health Care Administration Este Málaga-Axarquía and Serranía, Málaga. Subject of study: Immobilized Programme patients without UPP. Resources: Authors’ questionnaire including among others: demographic data, hospital admission date, Braden and EMINA scales. Sample: 353 patients, simple random sampling. Result: The original scales support internal consistency with alpha superior to 0.7. Establishing new cut-off points discriminating patients with or without UPP threat, resulting sensitivity of 61%- 89% and specificity 64%-70%. The classified scales have a precisions as a diagnostic method equal or superior to 65%. OR are significant, indicating existing differences under threat of UPP according to new cut-off points. Cut-off points’ selected resulted in: High sensitivity threat ≤10% ≥ 95%, Braden’s scale average ≤ 10, EMINA 12-15. Moderate threat 10%,

Fiabilidad de las escalas de Braden y EMINA en pacientes de atención domiciliaria incluidos en programa de inmovilizados / Reliability in Braden and EMINA's scales for patients in domiciliary, included in the immobilized patients' programme

Objetivo: comprobar la fiabilidad de las escalas de Braden y EMINA (escalas de valoración del riesgo de úlceras por presión) en atención domiciliaria. Método: estudio observacional de tipo transversal. Ámbito de estudio: Área de Gestión Sanitaria Este de Málaga-Axarquía y Área de Gestión Sanitaria Serranía, ambas de Málaga. Sujetos de estudio: pacientes incluidos dentro del Programa de Inmovilizados sin úlceras por presión. Instrumentos: escalas de Braden y EMINA. Muestra: 30 pacientes, usando una técnica de muestreo aleatorio simple. Resultados: Escala de Braden: Alfa de Cronbach de 0,78 para ambos observadores. Coeficiente de correlación intraclase (CCI) para la puntuación total de la escala, 0,968. El índice kappa ponderado para cada uno de los 6 ítems de la escala oscila entre 0,685 que es el más bajo y corresponde a fricción y deslizamiento y 1,00 para el más alto, que corresponde a percepción sensorial. Escala EMINA: el Alfa de Cronbach oscila entre 0,69 y 0,73 entre observadores. Coeficiente de correlación intraclase para la puntuación total de la escala, 0,974. El índice kappa ponderado para cada uno de los 5 ítems de la escala oscila entre 0,750, el más bajo que corresponde a la actividad, y 1,00 para el más alto, que corresponde a nutrición. Conclusiones: la escala de Braden tiene mayor consistencia interna, aunque el grado de acuerdo cuando se utilizan las escalas de manera categórica es superior en la EMINA. Ambas escalas son instrumentos fiables para el uso en atención domiciliaria, aunque sería conveniente establecer nuevos puntos de corte, para definir o categorizar el riesgo en esta población

Objective: Assessing reliability of the Braden and EMINA scales (Rating Scales for the Risk of pressure sores) in-home care. Method: Cross-sectional study. Population of study from Málaga: area of Heath Management East Málaga-Axarquia and mountainous region. Subjects of study: Patients entered in the programme of immobilize persons without pressure sore. Questionnaires: Braden and EMINA. Sample: 30 patients selected by simple randomisation. Results: Braden Scale: Cronbach's coefficient alpha 0.78 for both ratters. The Intraclass correlation coefficient (ICC) is 0.968. Kappa values for each of the 6 items vary from 0.685 for the friction and slipping item and 1 for the sensorial perception item. EMINA Scale: Cronbach's coefficent alpha 0.69 and 0.73 for each of the two raters, respectively. The Intraclass correlation coefficient (ICC) is 0.974. Kappa values for each of the 6 items vary from 0.750 for the activity item and 1 for the nutrition item Conclusions: The internal consistency of Braden scales is higher than the consistency of the EMINA scale. However, when the individual item agreement between raters was higher for the EMINA than for the Braden. Both scales, as continuous, are reliable instruments to be used for in-home care, although it would be convenient to establish new cut-off points for the scales in order to categorise the risk of pressure sores for this type of population

[Breaking bad news in medicine: strategies that turn necessity into a virtue]. / Comunicando malas noticias en Medicina: recomendaciones para hacer de la necesidad virtud.

Breaking bad news is one of physician's most difficult duties. In spite of this, communication skills are considered a minor professional ability. Bad news is defined as any news that drastically and negatively alters the patient's view of his/her future. Patients never forget where, when and what bad news they were told. The factors that make communicating bad new difficult may come from the sociocultural setting of the patient or the doctor. Randomized studies have shown that communication learning skills may cause a positive impact on the person giving and receiving the bad news. In order to facilitate this task, a practical and dynamic 6-step protocol, described by Baile and Buckman, that may be useful for this task, is described.

Comunicando malas noticias en Medicina: recomendaciones para hacer de la necesidad virtud / Breaking bad news in medicine: strategies that turn necessity into a virtue

Comunicar malas noticias es una de las tareas más difíciles que deben enfrentar los médicos, a pesar de lo cual ha sido considerada como una competencia menor. Podemos definir la mala noticia como aquella que drástica y negativamente altera la propia perspectiva del paciente en relación con su futuro. Los receptores de malas noticias no olvidan nunca dónde, cuándo y cómo se les informó de ella. Los factores que dificultan la comunicación de malas noticias pueden provenir del ambiente sociocultural, del paciente o del propio médico. Estudios aleatorizados han demostrado que el aprendizaje de habilidades de comunicación puede producir un impacto positivo tanto en el dador como en el receptor de malas noticias. Con el fin de facilitar esta tarea se describe un protocolo práctico y dinámico de 6 pasos, descrito por Baile y Buckman, que puede ser de utilidad para cumplir esta tarea

Breaking bad news is one of physician's most difficult duties. In spite of this, communication skills are considered a minor professional ability. Bad news is defined as any news that drastically and negatively alters the patient's view of his/her future. Patients never forget where, when and what bad news they were told. The factors that make communicating bad new difficult may come from the sociocultural setting of the patient or the doctor. Randomized studies have shown that communication learning skills may cause a positive impact on the person giving and receiving the bad news. In order to facilitate this task, a practical and dynamic 6-step protocol, described by Baile and Buckman, that may be useful for this task, is described

Infección orofaríngea y sepsis: ¿una relación olvidada? / Oeropharyngeal infection and sepsis: a forgotten relationship?

El síndrome de Lemierre (SL) es una grave complicación de las infecciones orofaríngeas. La rareza de la entidad en la era antibiótica ha favorecido su olvido por parte de los médicos como causa de sepsis en jóvenes. No obstante, se siguen produciendo casos esporádicos. La entidad se caracteriza por una agresiva inflamación del espacio parafaríngeo lateral, la aparición de tromboflebitis de la vena yugular interna y el desarrollo de émbolos sépticos a distancia. El diagnóstico es esencialmente clínico y requiere de un alto índice de sospecha. La ecografía-doppler color y la tomografía computadorizada contrastada son muy útiles para confirmar el diagnóstico y realizar el seguimiento clínico. El tratamiento se basa en la administración de antibióticos a largo plazo y el drenaje quirúrgico de las colecciones purulentas. Presentamos un caso de SL con el doble objetivo de recordar que la entidad no está erradicada, y siguen presentándose casos de la misma, y subrayar la importancia crucial que tiene un diagnóstico precoz para su curación (AU)

Lemierre´s syndrome (LS) is a severe complication of oropharyngeal infections. Due to its very low incidence in the actual antibiotic era, clinicians have lack of familiarity with this condition. However, a “drip” of cases is continuously turning up. The syndrome is characterized by aggressive inflammation of the lateral parapharyngeal space, thrombophlebitis of the internal yugular vein and metastasic abscesses in different organs. Diagnosis is basically made on clinicalgrounds and an high index of suspicion is critically needed for doing it. Both color doppler ultrasonography and contrast-enhanced CT scanning are very useful to confirm the diagnosis and to carry out a clinical follow-up. Treatment involves a prolonged course of antibiotics and surgical drainage of abscess if deemed necessary. A case of LS is presented with a double target: to recall that this condition is not eradicated at the present and to highlight that an early diagnosis is crucial for achieving an optimal clinical outcome (AU)

El infarto de miocardio en el diabético: implicaciones clínicas, pronósticas y terapéuticas en la era trombolítico-intervencionista / Myocardial infarction in diabetics: clinical, prognostic and therapeutic implications in the thrombolyticinterventionist era

Objetivo. El propósito de esta revisión es analizar la información generada en la actual era trombolítico-intervencionista con respecto a las implicaciones clínicas, pronósticas y terapeúticas del paciente diabético con infarto de miocardio. Fuente de datos. Búsqueda bibliográfica mediante la base de datos MEDLINE desde 1966 hasta 2000. Se usó metodología booleana usando los términos: infarto agudo de miocardio, diabetes mellitus, pronóstico, angioplastia coronaria transluminal percutánea y cirugía de injerto coronario. Por su relevancia se seleccionaron 88 estudios. Resultados. El aumento de la morbilidad y la mortalidad en el infarto del diabético se explica por el peor perfil basal de riesgo y por las mayores tasas de reinfarto y fallo cardíaco de estos pacientes. Los diabéticos con infarto se benefician particularmente de la administración de trombolíticos, bloqueadores beta, inhibidores de la enzima conversiva de la angiotensina y de un estricto control glucometabólico. Debido a la afectación más difusa de los vasos coronarios y a la aterogénesis más acelerada, los diabéticos presentan peores resultados con las técnicas de revascularización que los no diabéticos. Aunque no está definitivamente establecido, en diabéticos con afectación multivaso la revascularización quirúrgica ha demostrado ser superior a la percutánea. El papel del stent y de los antagonistas de las glucoproteínas plaquetarias IIb/IIIa para optimizar los resultados de la angioplastia en el diabético, aunque prometedor, está pendiente de confirmación. Conclusión. Los diabéticos que sufren un infarto de miocardio deben ser considerados per se como de alto riesgo y, por esta misma razón, se benefician más que los no diabéticos de las modernas intervenciones farmacológicas y revascularizadoras. En el momento actual, están en marcha estudios aleatorizados que permitirán definir en los próximos años cuál será la estrategia de revascularización y la medicación coadyuvante más efectiva en estos pacientes (AU)

Perforación ventricular por electrocatéter de marcapasos transitorio: prevención y tratamiento / Temporary pacing electrode ventricular perforation: prevention and treatment

Las complicaciones de la perforación por electrocatéter son infrecuentes, siendo las más graves el taponamiento y la pérdida de estimulación. Aparece durante la colocación del electrocatéter o tras días o semanas. Las herramientas para su prevención son: radiología, determinación de umbrales de sensado y estimulación y electrocardiograma (ECG). El ECG intracavitario informa del grado de contacto entre electrodo y el miocardio según cuatro patrones fundamentales: a) electrodo libre en el ventrículo, b) electrodo implantado en el endocardio; c) patrón de empotramiento, y d) patrón de perforación. El registro intracavitario simultáneo del ECG por el electrodo proximal y el distal permite la identificación del empotramiento y la perforación del catéter, y facilita su resolución, guiando y asegurando la retirada del electrocatéter hasta su posición correcta. Se presenta un caso de perforación ventricular por marcapasos transitorio para ilustrar la identificación del patrón de perforación y el resultado de la retirada del electrocatéter, guiada por el registro intracavitario continuo (AU)

Estreñimiento como forma de presentación de un feocromocitoma / No disponible

No disponible

El electrocardiograma en la estimación inicial del pronóstico de pacientes con infarto agudo de miocardio / Early assessment of outcome by electrocardiogram in patients with acute myocardial infarction

Objetivo. Revisar la información con importancia pronóstica que puede obtenerse a partir de los electrocardiogramas iniciales de los pacientes con infarto agudo de miocardio. Fuente de datos. Investigación bibliográfica realizada mediante la base de datos Medline®, en CD-ROM, del período comprendido entre enero de 1970 y abril de 1999. Se seleccionaron y cribaron publicaciones en español, inglés, francés e italiano, en las cuales se hubiera utilizado algún tipo de análisis estadístico de los datos. Resultados. El examen minucioso de los electrocardiogramas iniciales de los pacientes con infarto agudo de miocardio permite precozmente:1. Detectar marcadores de susceptibilidad aumentada a las arritmias malignas.2. Reconocer la presencia o ausencia de reperfusión tras la administración de trombolíticos.3. Describir patrones eléctricos característicos de ciertas lesiones coronarias.4. Identificar pacientes con infartos más extensos y peor pronóstico. Esta información es de relevancia clínica para la selección de los pacientes que obtendrán un mayor beneficio de técnicas de revascularización más agresivas y de un período de monitorización más prolongado. Conclusiones. El electrocardiograma al ingreso es muy útil para la estimación inicial del riesgo en pacientes con infarto agudo de miocardio. Para ello se requiere realizar un registro ampliado de 18 derivaciones (AU)

[The treatment of myasthenia gravis by video thoracoscopic thymectomy. The technic and the initial results]. / Tratamiento de la miastenia grave mediante timectomía videotoracoscópica. Técnica y resultados iniciales.

The primary role of thymectomy for the treatment of myasthenia gravis is currently undisputed. Traditionally, the approach of choice has been sternotomy, although a transcervical route has also been advocated because of its lower rate of associated morbidity. Our department performed thymectomy using a video-assisted thoracoscopic technique in 7 patients (2 men and 5 women) between March 1993 and October 1995. The patients' mean age was 43.4 years (range 20 to 66 years). Complications were few, consisting of 2 cases of pneumothorax due to contralateral opening of the pleura, resolved by pleural drainage. No deaths occurred. Clinical results over periods of observation ranging from 14 to 44 months were excellent in 2 cases of complete remission; good in 3 patients with considerable reduction in drug requirements; and fair in 2 patients who continued to need the same doses of medication throughout the 14 months after thymectomy. The technique we propose is less aggressive than mid-sternotomy, offering incontrovertible advantages and leading to faster. No patient required assisted ventilation for longer than 4 hours and the maximum time spent in the intensive care unit was 24 hours. We therefore suggest that thymectomy to treat myasthenia gravis be performed by thoracoscopy.

[Prognostic evaluation of post-infarction patients using two-dimensional echocardiography, late ventricular potentials and baroreflex sensitivity]. / Valoración pronóstica pacientes postinfarto mediate la ecocardiografía bidimensional, los potenciales tardíos ventriculares y la sensibilidad barorrefleja.

BACKGROUND: Although many variables are useful predictors of post-infarction mortality, their predictive positive values are weak when applied individually. The aim of this study was to determine the prognostic value of the combination of left ventricular ejection fraction, ventricular late potentials and baroreflex sensitivity. PATIENTS AND METHODS: We studied 69 consecutive post-infarction patients. On the day of their discharge from the coronary unit, all patients underwent a two-dimensional echocardiography, to determine the ejection fraction as well as a high resolution electrocardiogram to detect late potentials. To a subset of 49 patients was carried out to learn their baroreflex sensitivity. The patients were followed for 14 +/- 7 months and the following cardiac end points were considered: sudden cardiac death, non sudden cardiac death and non-fatal episodes of sustained ventricular tachycardia or ventricular fibrillation. RESULTS: There were 8 end points: 3 sudden cardiac deaths, 3 non sudden cardiac deaths and 2 successfully resuscitated sustained ventricular tachycardia episodes. The rate of fibrinolysis was 55%. An ejection fraction < 45%, the presence of late potentials and a baroreflex sensitivity < 3.0 msec/mmHg were univariate predictors with predictive positive values of 33%, 24% and 16%, respectively. When ejection fraction < 45%, late potentials and baroreflex sensitivity < 3.0 were combined, we found a significant increase in the positive predictive value (50%). CONCLUSION: The combined determination of ejection fraction, ventricular late potentials and baroreflex sensitivity allows us to identify subset postinfarction patients with a high rate of cardiac complications.

Comparative retrospective study of surgical treatment of spontaneous pneumothorax. Thoracotomy vs thoracoscopy.

BACKGROUND: Since May 1992 we have used video-assisted thoracic surgery (VATS) for the treatment of the spontaneous pneumothorax. In this study we review the results obtained with this technique and we compare them with those obtained by conventional surgery (1976-1992). METHODS: 110 patients (98 males and 12 females, age 15-83 years) were operated by VATS, and 627 patients (567 males and 60 females, age 14-89 years) by conventional surgery. The surgical technique and the complications are compared. No one died. RESULTS: Although the number of complications was greater in the first group than in the second one (29.5% vs 15.1%), this is attributed to the lack of experience among surgeons in the first cases; which complications nearly disappeared in the last 60 patients. Less pain, better recovery, and shorter hospital stay resulted. CONCLUSIONS: For us VATS is the ideal technique with which to treat spontaneous pneumothorax.

Acidosis impairs rabbit trabecular smooth muscle contractility.

PURPOSE: The aim of our study was to define the effects of acidosis on the contractility of trabecular smooth muscle. METHODS: Rabbit corpus cavernosal strips were mounted in organ chambers to measure isometric tension. Additionally, intracellular free Ca2+ concentration ([Ca2+]i) and tension were measured simultaneously utilising the intracellular fluorescent dye, FURA-2, and isometric tension recordings. RESULTS: Contraction of corpus cavernosum smooth muscle following transmural electrical stimulation (TES) of constrictor nerves or exposure to norepinephrine was depressed under acidic (pH 6.9) vs. control (pH 7.4) conditions. Twenty mM K(+)-induced contractions were also inhibited by acidosis, however 40, 80, and 120 mM K+ contractions were unaffected. Relaxation responses to acetylcholine and electrical stimulation, in phenylephrine contracted tissues, were unaffected by acidosis. Tissues contracted with 20 mM K+ under control conditions, relaxed approximately 50% when exposed to an acidic environment. This relaxation was blocked by exposing the tissue to 80 mM K+. Acidic conditions inhibited basal tone and [Ca2+]i as well as normal increases in both intracellular free Ca2+ and tension upon exposure to 20 mM K+, while 80 mM K(+)-induced increases in Ca2+ and tension were comparable under both neutral and acidic conditions. CONCLUSION: Acidosis impairs trabecular smooth muscle contractility. This alteration is probably secondary to the interference of [H+] with the intra and extracellular mechanisms that regulate homeostasis of [Ca2+]i. Since acidosis is an early complication of ischemic priapism, we propose that the reduced contractility of trabecular smooth muscle may be a significant factor in the perpetuation of the ischemic state.

[An assessment of the resectability of lung cancer by exploratory video thoracoscopy]. / Valoración de la resecabilidad del cáncer de pulmón mediante videotoracoscopia exploradora.

We describe our experience using exploratory video-assisted thoracoscopy (EVT) to definitively evaluate resectability in patients with lung cancer who are candidates for surgical resection. In a single procedure we performed full visual and surgical exploration of the pleural cavity, lung, mediastinum, as well as of the pericardial cavity when required. The technique was used in 151 patients. Resection was judged non viable in 18 (11.9%) and performance of exploratory thoracotomy was deemed unnecessary. In 3 cases thoracotomy proved necessary for exploration. Nineteen patients were treated by video-assisted surgery; standard thoracotomy was used to resect 111. Morbidity and mortality were null in the group undergoing EVT in whom resection was judged viable. We conclude that EVT should be used in all patients with lung cancer who are being considered for surgery before a thoracotomy is performed. EVT can be performed as part of the same surgical act, as it supposes a savings in exploratory thoracotomies (amounting to 11.9% in our series).

[Disparity between cytohistopathological results of diagnostic specimens and the resected tumor piece in bronchopulmonary carcinoma]. / Disparidad entre los resultados citohistopatológicos de los especímenes diagnósticos y la pieza tumoral resecada en el carcinoma broncopulmonar.

In 88 patients diagnosed and intervened of lung carcinoma, we evaluate the security of the Diagnostic method--cytology: sputum, brushed bronchial, bronchial aspiration, puncture pulmonary aspiration and histology of the bronchial biopsy--when we correlate them with the histology of the dried up tumour. From the 88 patient, in 11 (12.5%) there was a disparity between some specimen and the piece tumour. If we analyze the specimen: the bronchial biopsy, was different in 3 cases, (4.8%); the brushed and the bronchial biopsy, aspiration in 2, (2.7% and 2.3% respectively); the puncture pulmonary aspiration in 6, (26%) and the cytology of sputum in 2 cases, (2.4%). In 8 patients (9%), the outputs of some specimen were not conclusive, if we remove these we find that: the bronchial biopsy was not conclusive in 2 cases, (3.2%), the brushed bronchial in 5, (6.8%); the bronchial aspiration in 9 (10.2%) and the cytology of sputum in 2 cases, (2.4%). With this data we could infer that sometimes the positive outputs of the specimen have no correlation with the histology of the tumour dried up. This disparity has not been observed in the oat-cells. Therefore when we send the specimens to the pathologist, it would always be advisable for him to inform us if there are any different cells belonging to the principal group of the tumor.

[Left splanchicectomy with videothoracoscopy for the control of pain in cancer of the esophagogastric union with invasion of the celiac plexus]. / Esplacnicectomía izquierda videotoracoscópica para el control del dolor en el cáncer de unión esofagogástrica con invasión del plexo celíaco.

Blockade of the celiac plexus and the splanchnic nerves to combat abdominal pain can be achieved by percutaneous injection of local anesthetics or alcohol, or by thoracotomy. We describe the technique for performing splanchnicectomy with video-thoracoscopy in palliative surgery for cancer of the esophagogastric union, discussing the excellent results obtained immediately in 2 patients.

[Treatment of spontaneous pneumothorax in patients over 70 years of age]. / Tratamiento del neumotórax espontáneo en pacientes mayores de 70 años.

Forty-eight patients over the age of 70 with spontaneous pneumothorax (SP) are analyzed. The severity of the clinical picture is conditioned by the presence of earlier lung lesions, particularly related to emphysema, and by the degree of respiratory failure prior to SP. Treatment guidelines are listed. Pleural drainage/aspiration, applied in all cases, was of no avail in 69%. Tetracycline was injected into the pleural space of 23 patients, with failure recorded in 35%. Talc was applied by thoroscopy in 5 patients, to no avail. Video-assisted endoscopic surgery was carried out in 4 patients, with good results in 3. Surgery with access by lateral thoracotomy was carried out in 20 patients, with a single failure that was explained by the patient's condition.