Papel del laboratorio clínico en la gestión de la demanda: un nuevo horizonte / The role of clinical laboratories in the management of the demand for analyses: a new horizon

Introducción. Es necesario establecer estrategias en el laboratorio clínico para adecuar la demanda analítica a las necesidades clínicas (gestión de la demanda analítica). Material y métodos. Se definieron una serie de indicadores de «sobreutilización de pruebas de laboratorio», según criterios de medicina basada en la evidencia durante los años 2012 y 2013, para medir el uso excesivo del laboratorio y se procedió a cuantificar, en términos de eficiencia (costes), el ahorro que suponía a la organización no realizar este grupo de pruebas innecesarias y, en algunos casos, redundantes. Resultados. El porcentaje de sobreutilización del laboratorio en las distintas magnitudes estudiadas osciló de 9,2 al 95,6%, según distintas áreas de conocimiento en el laboratorio, en el año 2012; y entre 4,6 al 96% en 2013. Esto ha generado un ahorro total de 90.954,84 euros en 2012 y de 121.749,26 euros en el año 2013. Destaca que el 8% de los estudios genéticos solicitados correspondían a pacientes a los que ya se le había realizado dicha prueba; sin embargo sus resultados no habían sido consultados por los clínicos peticionarios. Conclusiones. Nuestra estrategia ha supuesto un importante ahorro económico para la organización y para el área sanitaria. El papel del facultativo del laboratorio clínico en la gestión de la demanda analítica para adecuar las solicitudes a la evidencia científica es hoy clave en el ámbito sanitario, que busca más que nunca la optimización de los recursos y la eficiencia (AU)

Introduction. Strategies need to be established in clinical laboratories in order to cope with the continuous demand for analyses to be carried out (analytical demand management). Materials and methods. A group of quality indicators, defined as «laboratory tests overuse indicators», were introduced according to evidence-based medical criteria during a two-year period, 2012 and 2013, to assist in the management of the constant demand for analyses and to quantify, by employing efficiency terms (costs), the accumulated savings after the removal of unnecessary and, sometimes, redundant tests. Results. The percentage of rejected clinical tests, based on taking into account the newly introduced overuse quality indicators, and according to the various clinical laboratory areas, ranged between 9.2 and 95.6% in 2012, and between 4.6 and 96% in 2013. This has resulted in a total saving of 90,954.84 euros and 121,749.26 euros in each year, respectively. It should be emphasized that 8% of the requested genetic studies corresponded to patients who had already undergone such laboratory tests. However, the medical staff had not reviewed their results. Conclusions. Our strategy has resulted in important savings for the organization and the health system overall. The role of clinical laboratory professionals in the management of the demand for analyses, according to evidence-based medical criteria, has become crucial in healthcare and seeks, more than ever, efficiency and optimization of the available resources (AU)

Utilidad de la monitorización de la presión intraabdominal en el niño crítico / Utility of monitoring intra-abdominal pressure in critically ill children

Objetivo: Valorar la utilidad de la medición de la presión intraabdominal (PIA) intravesical para identificar a los pacientes con riesgo de desarrollar hipertensión intraabdominal; analizar los factores que influyen en la PIA, y valorar su relación con el pronóstico. Pacientes y métodos: Estudio prospectivo observacional en niños en estado crítico en los que se monitorizó la PIA en el momento de presentar clínica de hipertensión intraabdominal. Se analizaron las siguientes variables: edad, sexo, motivo de ingreso, patología de base, cirugía previa, presión arterial, frecuencia cardíaca, presión venosa central, diuresis, tratamiento con fármacos vasoactivos, sedación, relajación muscular, ventilación mecánica, técnicas de depuración extrarrenal, oxigenación con membrana extracorpórea y mortalidad. Resultados: Se estudió a 39 pacientes. A las 24 h de iniciar la monitorización, un 74,4% presentaba una PIA ≥12mmHg, un 33,3%>15mmHg y un 15,4% >20mmHg. A las 48h un 59% presentaba PIA ≥12mmHg. Se observó correlación de la PIA con la presión venosa central a las 24 y 48h (r=0,500; p=0,001 y r=0,360; p=0,04, respectivamente). No existió correlación con el resto de los parámetros analizados. Solo 9 pacientes precisaron descompresión urgente y ningún paciente desarrolló síndrome compartimental abdominal. Conclusiones: La medición de la PIA puede resultar útil para diagnosticar y tratar precozmente la hipertensión intraabdominal y prevenir el síndrome compartimental abdominal, por lo que se debería realizar en los niños críticos con patología abdominal(AU)

Objective: To assess the usefulness of intra-abdominal pressure (IAP) measurement, by the intra-vesical method, in order to identify those patients at risk of developing intra-abdominal hypertension, as well as to analyse the factors that affect the IAP, and to determine their influence on the prognosis in critically ill patients. Patients and methods: Prospective observational study in critically ill children in whom the IAP was monitored as soon as signs of intra-abdominal hypertension appeared. The following variables were analysed: age, sex, reason for admission, underlying disease, previous surgeries, blood pressure, heart rate, central venous pressure, urine output, inotropic therapy, sedation, muscle relaxation, mechanical ventilation, renal replacement techniques, extracorporeal membrane oxygenation, and mortality. Results: A total of 39 patients were studied. At 24hours from initiating the monitoring of IAP, 74.4% showed IAP ≥ 12mmHg, 33.3%>15mmHg, and 15.4%>20mmHg. After 48hours, 59% had intra-abdominal hypertension. There was a correlation between the central venous pressure (CVP) and IAP at 24 and 48hours (r=0.500, P=0.001 and r=0.360, P=0.040, respectively). There was no correlation with the other parameters. Only 9 patients required urgent decompression and none developed abdominal compartment syndrome. Conclusions: AP monitoring can be useful to diagnose and to promptly treat intra-abdominal hypertension, and thus to prevent the abdominal compartment syndrome. Therefore, it should be measured in critically ill children with abdominal pathology

[Utility of monitoring intra-abdominal pressure in critically ill children]. / Utilidad de la monitorización de la presión intraabdominal en el niño crítico.

OBJECTIVE: To assess the usefulness of intra-abdominal pressure (IAP) measurement, by the intra-vesical method, in order to identify those patients at risk of developing intra-abdominal hypertension, as well as to analyse the factors that affect the IAP, and to determine their influence on the prognosis in critically ill patients. PATIENTS AND METHODS: Prospective observational study in critically ill children in whom the IAP was monitored as soon as signs of intra-abdominal hypertension appeared. The following variables were analysed: age, sex, reason for admission, underlying disease, previous surgeries, blood pressure, heart rate, central venous pressure, urine output, inotropic therapy, sedation, muscle relaxation, mechanical ventilation, renal replacement techniques, extracorporeal membrane oxygenation, and mortality. RESULTS: A total of 39 patients were studied. At 24hours from initiating the monitoring of IAP, 74.4% showed IAP ≥ 12mmHg, 33.3%>15mmHg, and 15.4%>20mmHg. After 48hours, 59% had intra-abdominal hypertension. There was a correlation between the central venous pressure (CVP) and IAP at 24 and 48hours (r=0.500, P=.001 and r=0.360, P=.040, respectively). There was no correlation with the other parameters. Only 9 patients required urgent decompression and none developed abdominal compartment syndrome. CONCLUSIONS: IAP monitoring can be useful to diagnose and to promptly treat intra-abdominal hypertension, and thus to prevent the abdominal compartment syndrome. Therefore, it should be measured in critically ill children with abdominal pathology.

Protocolo de actuación ante una neumonía que no se resuelve / Protocol for action in the event of non-resolving pneumonia

Las infecciones agudas del tracto respiratorio inferior son las más frecuentes en la edad pediátrica; aproximadamente el 1,5% de ellas son neumonías. La incidencia de la neumonía es difícil de establecer, al tratarse de un proceso benigno sin obligación oficial de declararse, aunque se estima en 15-40/1.000 niños al año, según la edad. Las neumonías son la principal causa de morbilidad respiratoria en el mundo y la tercera causa de muerte en los países desarrollados. Su resolución es habitual, aunque en ciertas ocasiones la evolución clínica y radiológica no es favorable a pesar de realizar un tratamiento supuestamente adecuado, lo que obliga a llevar a cabo una sistemática diagnóstica para intentar aclarar las causas de esta evolución anormal a fin de realizar un tratamiento correcto (AU)

Acute lower respiratory tract infections (LRTIs) are the most common infections in children; approximately 1.5% of those infections are pneumonias. It is difficult to establish the incidence of pneumonia since it is a benign process with no official reporting obligation, but it is estimated that there are 15 to 40cases per thousand children and year according to age. Pneumonias are the main cause of respiratory morbidity worldwide and the third cause of death in developed countries; commonly, resolution is the norm. However, in some cases the clinical and radiological evolution is not favourable in spite of a supposedly appropriate treatment. In those cases, a systematic diagnosis is required in order to clarify the causes of the abnormal evolution and establish a correct treatment (AU)

Triple vírica y alergia al huevo / MMR Vaccine and egg alergic

Las vacunas constituyen una de las medidas másefectivas en la lucha contra las enfermedades transmisibles.La utilización de las mismas de forma sistemáticapermite el control e incluso la erradicaciónde algunas de estas enfermedades.Uno de los objetivos de la Organización Mundialde la Salud es la erradicación del sarampión en 3 desus regiones entre las que se incluye la europea. Comoconsecuencia de lo anterior, se han desarrolladoplanes de actuación específicos en nuestro pais queincluyen entre sus estrategias la de alcanzar una altacobertura vacunal. La vacuna del sarampión está incluidaen el calendario vacunal en nuestro país desde1981, administrándose de forma conjunta a las dela rubéola y la parotiditis en forma de vacuna trivalente.Esta vacuna se obtiene mediante cultivo del virusen fibroblastos de embrión de pollo. La posibilidadde desarrollar una reacción anafiláctica tras suadministración en niños alérgicos al huevo aceleró eldesarrollo de otras vacunas desarrolladas en célulasdiploides humanas que se han venido utilizando ensustitución de la TV tradicional. Sin embargo, el ceseen la producción de una de ellas y la falta de disponibilidadde la otra, que además no incluye cepas delvirus de la parotiditis, ha supuesto el resurgir de lacontroversia en torno a la utilización de esta vacunaen caso de alergia al huevo

Vaccines are one of the most powerfull tools availablein the battle against infectious agents. The useof systematic vaccinnation allows both the controland erradication of some infectious diseases.As a primary target, regional measles eliminationinitiatives have been stablished in three of the WHOregions, being the European Region one of them.Therefore, specific actuation plans are being developedin our country, these national plans include intheir strategy to obtain a high coverage inmunization.In our country, since 1981, measles vaccine isincluded in the vaccine schedule, wich is simultaneouslydelivered with rubella and mumps vaccine(MMR). Measles virus used in the MMR is grown incultures of fibroblasts from chicken embryos. Therisk of anaphylaxis in egg allergic individuals aftervaccination promoted the research of two vaccinesgrown in diploid human cells (Triviraten and Moruviraten).These vaccines have been administrated toegg allergic patients in the last years in substitutionof traditional MMR. Taking into account that triviratenworld wide production has ceased and that moruviratennot only run out of stocks but also doesn`tinclude mumps vaccine, the controversial about theuse of MMR in egg allergic individuals has reappeared

[Study on bacteremia in the service of Internal Medicine of a group 2 hospital. Analysis of recent three years]. / Estudio de las bacteriemias en el Servicio de Medicina Interna de un hospital de grupo 2. Análisis de los tres últimos años.

INTRODUCTION: Bacteremia remains one of the most relevant problems in infectious disease. The interest of this study was to know the presentation and development pattern of bacteremia in our environment, in order to best prevent and treat this entity. PATIENTS AND METHOD: A retrospective, no interventional study, on significant bacteremia detected in the Service of Internal Medicine of a secondary level hospital over three years was carried out. Through the study length, from January 1 2001 until December 31 2003, 4,719 blood cultures were processed by the Service of Microbiology; of these, 1964 (41.6%) were submitted by the Service of Internal Medicine. Results were positive in 336 (17.1%); of these, 18 (24.1%) correlated with episodes of true bacteremia, and 255 (75.9%) were deemed as contaminations. RESULTS: Overall, 81 episodes of true bacteremia were studied, from 77 patients (4 patients presented with 2 episodes). An incidence rate of 28.25 episodes per 1000 hospital admissions was estimated. Mean age was 72 years (95% CI: 68.62-75.38). Males over 60 years-old were predominant (51.9%). Bacteremia was community-acquired in 75.3% of cases, and nosocomial in 24.7%. Commonest baseline diseases were elevated arterial blood pressure and diabetes mellitus. Bacteremia development was mostly related to genitourinary and vascular handling. Most of them were nephrourological (42.0%), respiratory (19.8%) and abdominal (13.6%) in origin. In our environment, Escherichia coli (33.0%) and Staphylococcus coagulase-negative (15.9%) were the most commonly isolated pathogens. Empiric antibiotic therapy was correct in 86.2% of cases; third generation cephalosporins were the most used. Overall mortality rate was 16% (13 patients), and bacteraemia-related mortality was 61%. CONCLUSIONS: A high incidence of bacteremia episodes is noteworthy, as compared with series from other centers. The percentage of episodes due to Staphylococcus coagulase-negative was significant, as it is the rule in recent years; thus, a thoroughly assessment of potential contaminants, as well as staff training in extraction techniques becomes necessary.

Estudio de las bacteriemias en el Servicio de Medicina Interna de un hospital de grupo 2. Análisis de los tres últimos años / Study of bacteremia in the service of internal medicine of a group 2 hospital. Analysis of recent three years

Introducción: La bacteriemia sigue siendo uno de los principales problemas de la patología infecciosa. El interés de realizar este estudio ha sido conocer el modelo de presentación y desarrollo de la bacteriemia en nuestromedio, con el propósito de prevenir y tratar mejor esta entidad. Pacientes y método: Se trata de un estudio retrospectivo, sin ningún tipo de intervención, de las bacteriemias significativas detectadas en el servicio de Medicina Interna de un hospital secundario durante tres años. Durante el periodo de estudio, 1 de enero de 2001 hasta el 31 de diciembre de 2003, se procesó en el Servicio de Microbiología Clínica 4.719 hemocultivos (HC), de los que 1964 (41,6%) fueron remitidos desde el servicio de Medicina Interna. Resultaron positivos 336 (17,1%) de los que 81 (24,1%) correspondieron a episodios de bacteriemia verdadera, y 255 (75,9%) se consideraron contaminaciones. Resultados: En total se estudiaron 81 episodios de bacteriemia verdadera correspondientes a 77 pacientes (sólo 4 pacientes presentaron dos episodios de bacteriemia). Se calculó una tasa de incidencia de 28.25 episodios por cada mil ingresos hospitalarios. La edad media fue de 72 años (IC 95%: 68,62-75,38). Predominaron los pacientes varones (51,9%) mayores de 60 años. El lugar de adquisición de la bacteriemia ha sido el medio extrahospitalario en el 75,3% de los casos y el nosocomial en el 24,7%. Las enfermedades de base más frecuentes fueron la hipertensión arterial y la diabetes. Las manipulaciones genitourinarias y vasculares fueron las más relacionadas con desarrollo de bacteriemia. Como foco de origen destacan por su frecuencia: nefrourológico (42.0%), respiratorio (19.8%) y abdominal (13,6%). En nuestro medio los patógenos más frecuentemente aislados han sido Escherichia coli (33,0%) y Staphylococcus coagulasa negativo (15,9%). El tratamiento antibiótico empírico fue correcto en el 86,2% de los casos, siendo el grupo de cefalosporinas de tercera generación el más utilizado. La mortalidad global fue del 16% (13 pacientes), y la directamente relacionada con la bacteriemia del 61%. Conclusiones: Destacamos una incidencia elevada de episodios de bacteriemia en comparación con otras series de centros de similares características. Hemos obtenido un porcentaje significativo de episodios por Staphylococcus coagulasa negativo como se viene analizando los últimos años, lo que nos obliga a una valoración minuciosa de los posibles contaminantes y al entrenamiento del personal sanitario en la técnica de extracción

Introduction: Bacteremia remains one of the most relevant problems in infectious disease. The interest of this study was to know the presentation and development pattern of bacteremia in our environment, in order to best prevent and treat this entity. Patients and method: A retrospective, no interventional study, on significant bacteremia detected in the Service of Internal Medicine of a secondary level hospital over three years was carried out. Through the study length, from January 1 2001 until December 31 2003, 4,719 blood cultures were processed by the Service of Microbiology; of these, 1964 (41.6%) were submitted by the Service of Internal Medicine. Results were positive in 336 (17.1%); of these, 18 (24.1%) correlated with episodes of true bacteremia, and 255 (75.9%) were deemed as contaminations. Results: Overall, 81 episodes of true bacteremia were studied, from 77 patients (4 patients presented with 2 episodes). An incidence rate of 28.25 episodes per 1000 hospital admissions was estimated. Mean age was 72 years (95% CI: 68.62-75.38). Males over 60 years-old were predominant (51.9%). Bacteremia was community-adquired in 75.3% of cases, and nosocomial in 24.7%. Commonest baseline diseases were elevated arterial blood pressure and diabetes mellitus. Bacteremia development was mostly related to genitourinary and vascular handling. Most of them were nephrourological (42.0%), respiratory (19.8%) and abdominal (13.6%) in origin. In our environment, Escherichia coli (33.0%) and Staphylococcus coagulase-negative (15.9%) were the most commonly isolated pathogens. Empiric antibiotic therapy was correct in 86.2% of cases; third generation cephalosporins were the most used. Overall mortality rate was 16% (13 patients), and bacteraemia-related mortality was 61%. Conclusions: A high incidence of bacteremia episodies is noteworthy, as compared with series from other centers. The percentaje of episodes due to Sthapylococcus coagulase-negative was significant, as it is the rule in recent years; thus, a thoroughly assessment of potential contaminants, as well as staff training in drawing techniques becomes necessary