Assessment of evidence and quality of clinical practice guidelines on deterioration of skin integrity: ulcers and chronic wounds / Evaluación de las evidencias y calidad de las guías de práctica clínica sobre deterioro de la integridad cutánea: úlceras y heridas crónicas.

Background. The epidemiological, social, and economic situation that surrounds the deterioration of skin integrity is a big problem for the health system. Its prevention and treatment create uncertainty and professional variability and it remains a priority to have good clinical practice guidelines (CPG). The objective was to determine the quality of the CPG on prevention and treatment of pressure ulcers (PU), venous ulcers of the leg (VUL) and diabetic foot ulcers (DFU). Methodology. Systematic review of the quality of Spanish and international CPG on PU, VUL and DFU. Bibliographic search in specialized sources. Selection of CPG, not older than 5 years (2010-2015). Use of the AGREE Instrument II and revision by 4 experts. Descriptive statistics. Results. Twenty-three CPG (10 PU, 6 VUL and 7 DFU), of which 4 were Spanish and 19 international. Eight CPG on PU, 3 VUL and 5 DFU were considered "Highly Recommended". Domain nº 2 (participation) and Domain nº 5 (applicability) were the worst valued. The quality of the evidence was "very good" in 19 GPC. The best CPG were the British NICE (PU), the Australian AWMA (VUL) and the Canadian RNAO (DFU). Conclusions. We observed a good methodological quality in the CPG on PU and DFU, but there needs to be improvement in the VUL. In general, it would be necessary to increase the participation of users, and describe possible barriers for the implementation of the CPG in clinical practice.

Study of Phylogenetic Relationships Among Fusarium oxysporum f. sp. dianthi Isolates: Confirmation of Intrarace Diversity and Development of a Practical Tool for Simple Population Analyses.

Fusarium wilt, caused by Fusarium oxysporum f. sp. dianthi, is the most important disease of carnation worldwide. Knowing the diversity of the F. oxysporum f. sp. dianthi population present in a carnation growing area is a key component of preventing dramatic losses in production. Sequence analyses of partial ß-tubulin, translation elongation factor 1α genes, and the full-length ribosomal DNA intergenic spacer (IGS) were conducted to resolve phylogenetic relationships in a wide collection of Spanish F. oxysporum f. sp. dianthi isolates, along with some representatives from Italy. We found that, among the three different gene regions, the IGS sequence was the best choice to resolve phylogenetic relationships among F. oxysporum f. sp. dianthi isolates. The phylogenetic tree generated with the complete IGS region was the only one showing a clear clustering of isolates according to the molecular group (virulence grouping) and the vegetative compatibility group. In order to develop a more practical tool based on a shorter DNA sequence to quickly analyze diversity in F. oxysporum f. sp. dianthi populations, we examined IGS nucleotide alignments and identified a region of approximately 300 bp that accumulates enough "informative" changes to resolve intraspecific relationships and determine pathogenic variants in F. oxysporum f. sp. dianthi. Moreover, the "condensed" alignment of this short IGS region showing only the informative positions revealed the existence of virulence group-discriminating positions. In addition to clarifying the phylogenetic relationships among F. oxysporum f. sp. dianthi isolates of the recently described race groups by using multigene genealogies, we have developed simple tools for the phylogenetic analyses of F. oxysporum f. sp. dianthi populations and the determination of the molecular group of uncharacterized F. oxysporum f. sp. dianthi isolates.

Valoración de la satisfacción materna con la analgesia epidural para el trabajo del parto / Assessment of maternal satisfaction with epidural analgesia during labour

Objetivos. Conocer el grado de satisfacción de las pacientes obstétricas a las que se les realiza la técnica epidural para el trabajo de parto. Material y métodos. Encuestas realizadas durante tres meses a las pacientes ingresadas en el Hospital Universitario Virgen de las Nieves (HUVN) a las que se les aplicó la técnica epidural para control del dolor para el parto. Resultados. Se recogieron 100 encuestas de un total de 105. La satisfacción media global de las pacientes (puntuación SERVQHOS) fue de 3,98 con una desviación estándar, DE±0,64 con mejor resultado en las cuestiones subjetivas: 4,10 con DE±0,68 y menor en las objetivas con 3,86 y DE±0,73. El 92% de las pacientes se mostraron satisfechas con la analgesia epidural, con un intervalo de confianza, IC al 95% entre 87-97%. El análisis de los factores demográficos no mostró asociación estadísticamente significativa entre la edad de las pacientes y un mayor grado de satisfacción; tampoco se encontraron diferencias estadísticamente significativas entre la nacionalidad y la valoración de la satisfacción con la técnica epidural. El grado de recomendación posterior fue de 98% en las pacientes satisfechas y 85,7% en las no satisfechas. Conclusiones. La proporción de pacientes satisfechas con la técnica fue muy elevada, siendo los aspectos subjetivos los mejor valorados (trato y confianza en profesionales)(AU)

Objective. To measure the overall satisfaction of obstetrics patients with epidural analgesia during labour, and in particular, with the technique and other subjective factors. Material and methods. An anonymous questionnaire was administered over a three-month period to patients who received analgesia to control pain during labour and who had vaginal delivery, in order to obtain information of the satisfaction with technique and their care. Results. Of the 100 patients who responded to the questionnaire, 92% were satisfied with the technique. The mild satisfaction measured by SERVQHOS score was 3.98 (SD±0.64). The score for the subjective aspects was 4.10 (± 0.68), which was better than objective ones. The recommendation rate was 98% for satisfied patients and 85.7% for those who were not satisfied. There were no differences between Spanish and foreign patients in their evaluation of the satisfaction. Conclusions. The proportion of patients satisfied with the technique was very high, and was the top rated subjective aspect (treatment and public confidence)(AU)

[Assessment of maternal satisfaction with epidural analgesia during labour]. / Valoración de la satisfacción materna con la analgesia epidural para el trabajo del parto.

OBJECTIVE: To measure the overall satisfaction of obstetrics patients with epidural analgesia during labour, and in particular, with the technique and other subjective factors. MATERIAL AND METHODS: An anonymous questionnaire was administered over a three-month period to patients who received analgesia to control pain during labour and who had vaginal delivery, in order to obtain information of the satisfaction with technique and their care. RESULTS: Of the 100 patients who responded to the questionnaire, 92% were satisfied with the technique. The mild satisfaction measured by SERVQHOS score was 3.98 (SD ± 0.64). The score for the subjective aspects was 4.10 (± 0.68), which was better than objective ones. The recommendation rate was 98% for satisfied patients and 85.7% for those who were not satisfied. There were no differences between Spanish and foreign patients in their evaluation of the satisfaction. CONCLUSIONS: The proportion of patients satisfied with the technique was very high, and was the top rated subjective aspect (treatment and public confidence).

Effect of nebivolol on cardiovascular changes associated with a rat model of insulin-resistance.

Nebivolol is a vasodilator that combines beta-adrenergic blocking activity with a relaxant effect on vascular smooth muscle cells (VSMC) mediated by the endothelial nitric oxide (NO) pathway. FFR provide a model of dietary-induced insulin-resistance syndrome, which has been used to study the pathophysiological mechanisms associated with this syndrome. Our main objective was to examine the effect of long-term administration of nebivolol on metabolic and cardiovascular variables in fructose-fed rats (FFR), a model in which an altered bioavailability of NO has been already described. Male Wistar rats were randomly assigned to 4 groups (n = 8 each): I. Control (C); II. Control + nebivolol (C+N): 1 mg/kg(-1) x day(-1) in drinking water during the last 4 weeks. III. FFR: rats receiving fructose in drinking water as a 10% (w/v) solution during 8 weeks, and IV. FFR+N: idem II plus III. During the 8 weeks experimental period, variations in systolic blood pressure (SBP), glucose tolerance test (GTT) and plasma thiobarbituric acid-reactive substances (TBARS) were assessed. At the end of this experimental period, rats were killed and heart and kidneys were excised for calculation of relative heart weight (RHW) and histological evaluation of lumen to media ratio (L/M) in renal arteries. Rats from FFR group increased their SBP and RHW, showed glucose intolerance and an increment in lipid peroxidation. Moreover, FFR showed vascular remodeling in renal arteries evidenced by changes in L/M. Although the metabolic changes were not reverted by the administration of nebivolol, this drug successfully decreased SBP, TBARS levels and reverted structural changes such as cardiac hypertrophy and renal arterial remodeling. Data demonstrate that nebivolol administration could participate in the reversion of cardiovascular structural changes associated with the insulin-resistance syndrome.

Dolor lumbar e incapacidad temporal / Low back pain and transient disability

Objetivo: Describir las características y duración de la incapacidad temporal (IT) por dolor lumbar (DL) en atención primaria, y aproximarnos a los factores que en ella influyen. Diseño: Estudio retrospectivo descriptivo. Emplazamiento: Atención primaria, Centro de Salud “El Greco”. Getafe. Área 10. Madrid. Participantes: Se incluyó en el estudio a todos los pacientes correspondientes a las 11 consultas de medicina de familia de nuestro Centro de Salud, que en el período comprendido entre junio de 1999 y octubre de 2001 habían estado en situación de IT por dolor lumbar (código L03 de la Clasificación Internacional de atención primaria, CIAP) y que habían sido dados de alta al finalizar por dicho período. Se obtuvo una población de estudio de 246 pacientes, 33 de los cuales tenían más de un episodio de IT por dolor lumbar. Mediciones principales: Mediante el programa OMI-AP, a través de su módulo OMI-AD, se obtuvo una base de datos que posteriormente fue analizada mediante el programa SPSS. Las principales variables del estudio fueron: sexo, edad, enfermedades psíquicas, duración media de la IT, diagnóstico final y motivo del alta. Resultados: La IT por dolor lumbar representó en nuestro estudio el 4,9% del total de IT del período, y el 3,9% del total de días de IT. El 66,3% de los pacientes eran varones. La media de edad se estimó en 39,6 años. En el 90,2% de los casos el cuadro de DL era de origen mecánico. El 16,7% de los pacientes tenían diagnosticada alguna enfermedad mental. Sólo dos paciente obtuvieron la incapacidad laboral permanente. La duración media de todas las IT fue de 14,7 días. Se separaron las IT en dos grupos: duración igual o inferior a 15 días y duración mayor de 15 días. En el 79,2% de los casos se encontraban en el primer grupo. En el análisis estadístico correlativo de variables, únicamente se encontró asociación estadísticamente significativa entre ala edad y la duración de la IT: los pacientes de más de 45 años tenían una media de duración en días de 20,75, frente a 11,17 días de los menores de 45 años. Conclusiones: En nuestra muestra predominan los varones frente a las mujeres en situación de IT por DL. La mayoría están en edades medias de la vida. De las variables que se correlacionaron, sólo se encontró una asociación significativa entre la edad y la duración de la IT, no encontrándose asociación entre la duración de la IT y la existencia de enfermedades psíquicas

Aim: To describe the characteristics and duration of transient disability (TD) caused by low back pain (LBP) in the Primary Health Care environment and to establish an approach to the factors influencing it. Design: Retrospective descriptive study. Setting: Primary Health Care, “El Greco” Health Care Centre, Getafe (Madrid, Spain). Participants: All the patients seen by the General Practitioners or Family and Community Medicine Physicians (11 physicians) in our Health Care Centre who in the period between June and October 2001 had been on sick leave (TD) due to LBP (code L03 of the International Primary Health Care Classification, ICP) and who had been discharged by the end of that period. The study population comprised 246 patients, 33 of whom had had more than one TD episode due to LBP. Main variables: Using the OMI-AD module of the OMI-AP programme a database was generated that was then analysed using the SPSS programme package. The main study variables were gender, age, psychic disturbanves, mean duration of TD, final diagnosis and cause of discharge. Results: TD due to LBP represented 4.9% of the total number of TDs during the study period, and 3.9%of the total number of TD days. Among the study population, 66,3% were males. The mean age of the patients was 39,6 years. The cause of the LBP was mechanical in 90,2% of the cases. A diagnosis of psychic disturbance had been established in 16,7% of the cases. Only two patients were granted Permanent Disability. The mean duration of sick leave due to TD was 14.7 days. Upon separing the sick leave periods into two groups (<=15 days or > 15 days), 79.2% of the cases were found to be in the first one. In the statistical correlation analysis of the variables, a statistically significant correlation was found to exist only between age and duration of TD: patients aged over 45 years had a mean TD duration of 20.75 days, while those below that age had a mean duration of only 11.17 days. Conclusions: In our sample males predominate over females in the TD due to LBP population. Most of the patients were I their middle age. Among the variables tested for correlation, a statistically significant association was observed only between age and duration of TD; there were no associations between duration of TD and presence or absence of psychic disturbances

[Domino or sequential liver transplantation. Is it a feasible technique?]. / El trasplante hepático dominó o secuencial, es una técnica factible?

BACKGROUND: In domino liver transplantation (LT), the explanted liver of a patient with familial amyloidotic polyneuropathy (FAP) is donated to another patient. PATIENTS AND METHOD: Between February 1999 and March 2001 we performed 131 LT with 121 cadaveric donors in our unit. Ten domino LTs were performed. RESULTS: Patients with FAP were younger (37 years) than recipients of the second LT (64 years). The evolution of patients undergoing transplantation for FAP was excellent and all are currently alive and without complications. Among recipients of the second LT, one patient died in the postoperative period. A further two patients died from tumoral recurrence and hepatitis C virus recurrence 18 months and 9 months after transplantation, respectively. The remaining patients have shown no symptoms of FAP during the follow-up. CONCLUSION: The results of this study show that domino LT is technically feasible. The technique increases the number of grafts without apparent risk either to the recipient with FAP or to the recipient of the latter's explanted liver.

[Hemodynamics of the cirrhotic patient during liver transplantation. Influence of the preservation of portal and vena cava flow]. / Hemodinamia del paciente cirrótico durante el trasplante hepático. Influencia de la preservación del flujo portal y de la vena cava.

OBJECTIVE: To describe the hemodynamic pattern of patients undergoing liver transplantation with preservation of portocaval flow. PATIENTS AND METHODS: A prospective study of 20 cirrhotic patients who had not previously undergone surgery for portal hypertension or had porto-systemic bypass, both of which have hemodynamic effects in the cirrhotic patient. The patients were transplanted with preservation of inferior vena cava flow and temporary portocaval shunt. RESULTS: The decrease in cardiac output during the anhepatic phase was only 10% and mean blood pressure (77.6 +/- 11 versus 76 +/- 10 mm Hg) and supply pressures (central venous pressure 9.1 +/- 5.5 versus 8.4 +/- 5.3 mm Hg; pulmonary capillary pressure 11.4 +/- 6.1 versus 11.3 +/- 7.4 mm Hg) remained stable. Likewise, no significant increase in systemic vascular resistance (614 +/- 223 versus 676 +/- 306 dyne-sec/cm5) or heart rate (90 +/- 14 versus 97 +/- 17 beats/min). The number of units of packed red cells was 2.7 +/- 2.5 and 35% of the patients required no transfusions. Diuresis was stable throughout the procedure (total diuresis 3.6 +/- 2.4 mL/Kg/h; anhepatic phase 1.3 +/- 1.5 mL/Kg/h). CONCLUSIONS: Creation of a portocaval shunt during the anhepatic phase of liver transplantation allows hemodynamic vital signs to be held stable, decreases the need for transfusion and maintains diuresis.

Hemodinamia del paciente cirrótico durante el trasplante hepático. Influencia de la preservación del flujo portal y de la vena cava / Hemodynamics of the cirrhotic patient during liver transplantation: the effect of preserving portocaval flow

OBJETIVO: Describir el patrón hemodinámico de aquellos pacientes sometidos a trasplante hepático con preservación de flujo caval y portal. PACIENTES Y MÉTODOS: Estudio prospectivo de un grupo de 20 pacientes cirróticos, sin cirugía de la hipertensión portal o derivación portosistémica previa que influya en la hemodinámica del paciente cirrótico, trasplantados según la técnica de preservación de vena cava inferior asociándose anastomosis porto-cava temporal. RESULTADOS: La disminución del gasto cardíaco durante la fase anhepática fue tan sólo del 10 por ciento, manteniéndose estables tanto la presión arterial media (77,6 ñ 11 frente a 76 ñ 10 mm Hg) como las presiones de llenado (presión venosa central: 9,1 ñ 5,5 frente a 8,4 ñ 5,3 mm Hg; presión capilar pulmonar: 11,4 ñ 6,1 frente a 11,3 ñ 7,4 mm Hg). Asimismo no hubo un aumento significativo de las resistencias vasculares sistémicas (614 ñ 223 frente a 676 ñ 306 dinas-s/cm5) ni de la frecuencia cardíaca (90 ñ 14 frente a 97 ñ 17 latidos/min). El requerimiento de concentrados de hematíes fue de 2,7 ñ 2,5 pudiéndose trasplantar el 35 por ciento de los pacientes sin transfusión. La diuresis se mantuvo estable a lo largo del trasplante (diuresis total: 3,6 ñ 2,4 ml/Kg/h; fase anhepática: 1,3 ñ 1,5 ml/Kg/h). CONCLUSIONES: la realización de una anastomosis porto-cava durante la fase anhepática del trasplante hepático permite mantener la estabilidad hemodinámica, así como disminuir los requerimientos transfusionales y mantener la diuresis (AU)

Risk factors for development of de novo neoplasia after liver transplantation.

Liver transplant recipients are at greater risk for de novo neoplasia, especially lymphoma and nonmelanoma skin cancer; however, risk factors for this complication have not been well studied. Clinical and pathological records of 137 consecutive liver transplant recipients who had survived for at least 1 year were reviewed to register de novo neoplasia. Ten variables were analyzed for their association with the development of de novo malignancies by means of a log-rank test and stepwise selection in a multivariate analysis using the Cox proportional hazard model. Thirty de novo neoplasias appeared in 22 of 137 transplant recipients between 12 and 104 months after orthotopic liver transplantation (OLT; median follow-up, 69 months): 14 patients had 21 skin cancers, 6 patients had solid-organ cancer, and 3 patients developed a lymphoproliferative disease. Probabilities of de novo neoplasia were 13% at 5 years post-OLT and 26% at 8 years post-OLT. The only associated risk factor for any neoplasia was age. Age and hepatocarcinoma were independent risk factors associated with skin cancer. That hepatocarcinoma in the explanted liver is an independent risk factor for skin cancer suggests there is individual susceptibility to both neoplasias.

Resultados clínicos de la utilización de la oclusión portal preoperatoria en el tratamiento quirúrgico de las metástasis hepáticas / Clinical results of the use of preoperative portal occlusion in the surgical treatment of hepatic metastases

Introducción. La oclusión portal preoperatoria (OPP) produce una hipertrofia del hígado contralateral. Gracias a ello podemos aumentar el índice de resecabilidad de algunos pacientes considerados inicialmente irresecables en función de un futuro remanente hepático insuficiente. Objetivo. Valorar la seguridad de la OPP y su eficacia en mejorar la resecabilidad de 8 pacientes inicialmente irresecables. Métodos. Desde enero de 1997 hasta diciembre de 1999 hemos realizado resecciones hepáticas por metástasis hepáticas de carcinoma colorrectal a 136 pacientes. En 8 casos (5,8 por ciento) el futuro parénquima hepático remanente, según la TC helicoidal, fue considerado insuficiente (< 40 por ciento), indicándose embolización portal percutánea en 6 casos. En los 2 casos restantes la decisión se basó en los hallazgos de la ecografía peroperatoria, practicándose ligadura de la porta homolateral a la lesión. En un caso la OPP se realizó en un paciente con metástasis hepáticas de tumor carcinoide. Resultados. La OPP pudo realizarse en todos los casos. No hubo complicaciones relacionadas con el procedimiento. La resección hepática se practicó a los 52 días de media post-OPP. La morbilidad fue del 50 por ciento (fístula biliar, absceso subfrénico, ascitis). La mortalidad postoperatoria fue de un caso por insuficiencia hepática. Conclusión. La OPP es una técnica segura y que aumenta el índice de resecabilidad de los pacientes con metástasis hepáticas de carcinoma colorrectal (AU)