Mortalidad en pacientes con hemorragia intracerebral asociada a anticoagulación oral. Eficacia de un protocolo de reversión y seguimiento clínico (proyecto HIC-ACO) / Mortality in patients with intracerebral haemorrhage associated with oral anticoagulation. Efficacy of a reversal protocol and clinical follow-up (ICH-OAC project)

Introducción: La hemorragia intracerebral espontánea asociada a anticoagulantes orales (HIC-ACO) presenta una elevada mortalidad. La aparición de nuevos fármacos anticoagulantes y protocolos de reversión aumenta el interés por esta entidad. Objetivos: El objetivo principal es determinar la tasa de mortalidad en pacientes con HIC-ACO (precoz, hospitalaria, global) en nuestra área sanitaria y analizar las principales variables relacionadas. El objetivo secundario es determinar la eficacia de las terapias de reversión de la anticoagulación (TRA), reflejada por la expansión radiológica del hematoma y el pronóstico funcional. Pacientes y métodos: Estudio prospectivo observacional que introdujo un protocolo dirigido al manejo de pacientes con HIC-ACO. Incluyó medidas generales y neuromonitorización, administración individualizada de TRA, tomografía craneal y seguimiento durante seis meses. Se recogieron los fármacos prescritos en el área durante este período, mortalidad y pronóstico funcional. Se diseñó un estudio bivariante y regresión logística para investigar variables relacionadas con la mortalidad. Resultados: Se incluyó a 49 pacientes durante tres años; de ellos, un 71,4% recibió TRA. La mortalidad fue del 16,3% (primeras 24 horas), el 53,1% (ingreso) y el 61,2% (180 días). Se observó una menor supervivencia entre pacientes con puntuaciones basales mayores en la National Institutes of Healt Stroke Scale (NIHSS) (p < 0,0001), valor de creatinina (p = 0,02), índice internacional normalizado (p = 0,048), volumen hemorrágico (p = 0,008), hidrocefalia (p = 0,015) y toma de acenocumarol (p = 0,030). Los pacientes que no recibieron TRA tuvieron una mayor mortalidad precoz (p = 0,003). La única variable relacionada con la mortalidad global de forma independiente fue la puntuación en la NIHSS basal (odds ratio = 1,282; intervalo de confianza al 95%: 1,023-1,608; p = 0,031)...(AU)

Introduction: Spontaneous intracerebral haemorrhage associated with oral anticoagulants (ICH-OAC) has a high mortality rate. The emergence of new anticoagulant drugs and reversal protocols increases interest in this entity. Objectives: The main objective is to determine the mortality rate in patients with ICH-OAC (early, in-hospital, global) in our health area and to analyse the main variables related to it. The secondary objective is to determine the efficacy of anticoagulation reversal therapies (ART) as reflected by radiological expansion of the haematoma and the functional prognosis. Patients and methods: A prospective observational study that introduced a protocol aimed at the management of patients with ICH-OAC. It included general measures and neuromonitoring, individualised administration of ART, cranial tomography and a six-month follow-up. Data on the drugs prescribed in the area during this period, mortality and functional prognosis were collected. A bivariate and logistic regression study was designed to investigate mortality-related variables. Results: Forty-nine patients were included over three years; of these, 71.4% received ART. Mortality was 16.3% (first 24 hours), 53.1% (admission) and 61.2% (180 days). Lower survival was observed among patients with higher baseline scores on the National Institutes of Health Stroke Scale (NIHSS) (p < 0.0001), creatinine value (p = 0.02), International Normalised Index (p = 0.048), bleeding volume (p = 0.008), hydrocephalus (p = 0.015) and acenocoumarol intake (p = 0.030). Patients who did not receive ART had a greater rate of early mortality (p = 0.003). The only variable independently related to overall mortality was the baseline NIHSS score (odds ratio = 1.282; 95% confidence interval: 1.023-1.608; p = 0.031)...(AU)

[Mortality in patients with intracerebral haemorrhage associated with oral anticoagulation. Efficacy of a reversal protocol and clinical follow-up (ICH-OAC project)]. / Mortalidad en pacientes con hemorragia intracerebral asociada a anticoagulación oral. Eficacia de un protocolo de reversión y seguimiento clínico (proyecto HIC-ACO).

INTRODUCTION: Spontaneous intracerebral haemorrhage associated with oral anticoagulants (ICH-OAC) has a high mortality rate. The emergence of new anticoagulant drugs and reversal protocols increases interest in this entity. OBJECTIVES: The main objective is to determine the mortality rate in patients with ICH-OAC (early, in-hospital, global) in our health area and to analyse the main variables related to it. The secondary objective is to determine the efficacy of anticoagulation reversal therapies (ART) as reflected by radiological expansion of the haematoma and the functional prognosis. PATIENTS AND METHODS: A prospective observational study that introduced a protocol aimed at the management of patients with ICH-OAC. It included general measures and neuromonitoring, individualised administration of ART, cranial tomography and a six-month follow-up. Data on the drugs prescribed in the area during this period, mortality and functional prognosis were collected. A bivariate and logistic regression study was designed to investigate mortality-related variables. RESULTS: Forty-nine patients were included over three years; of these, 71.4% received ART. Mortality was 16.3% (first 24 hours), 53.1% (admission) and 61.2% (180 days). Lower survival was observed among patients with higher baseline scores on the National Institutes of Health Stroke Scale (NIHSS) (p < 0.0001), creatinine value (p = 0.02), International Normalised Index (p = 0.048), bleeding volume (p = 0.008), hydrocephalus (p = 0.015) and acenocoumarol intake (p = 0.030). Patients who did not receive ART had a greater rate of early mortality (p = 0.003). The only variable independently related to overall mortality was the baseline NIHSS score (odds ratio = 1.282; 95% confidence interval: 1.023-1.608; p = 0.031). CONCLUSIONS: ICH-OAC has a high mortality rate, related to the use of acenocoumarol and regardless of the initial clinical situation. A lower rate of early mortality was found among patients who received ART.

TITLE: Mortalidad en pacientes con hemorragia intracerebral asociada a anticoagulación oral. Eficacia de un protocolo de reversión y seguimiento clínico (proyecto HIC-ACO).Introducción. La hemorragia intracerebral espontánea asociada a anticoagulantes orales (HIC-ACO) presenta una elevada mortalidad. La aparición de nuevos fármacos anticoagulantes y protocolos de reversión aumenta el interés por esta entidad. Objetivos. El objetivo principal es determinar la tasa de mortalidad en pacientes con HIC-ACO (precoz, hospitalaria, global) en nuestra área sanitaria y analizar las principales variables relacionadas. El objetivo secundario es determinar la eficacia de las terapias de reversión de la anticoagulación (TRA), reflejada por la expansión radiológica del hematoma y el pronóstico funcional. Pacientes y métodos. Estudio prospectivo observacional que introdujo un protocolo dirigido al manejo de pacientes con HIC-ACO. Incluyó medidas generales y neuromonitorización, administración individualizada de TRA, tomografía craneal y seguimiento durante seis meses. Se recogieron los fármacos prescritos en el área durante este período, mortalidad y pronóstico funcional. Se diseñó un estudio bivariante y regresión logística para investigar variables relacionadas con la mortalidad. Resultados. Se incluyó a 49 pacientes durante tres años; de ellos, un 71,4% recibió TRA. La mortalidad fue del 16,3% (primeras 24 horas), el 53,1% (ingreso) y el 61,2% (180 días). Se observó una menor supervivencia entre pacientes con puntuaciones basales mayores en la National Institutes of Healt Stroke Scale (NIHSS) (p lower than 0,0001), valor de creatinina (p = 0,02), índice internacional normalizado (p = 0,048), volumen hemorrágico (p = 0,008), hidrocefalia (p = 0,015) y toma de acenocumarol (p = 0,030). Los pacientes que no recibieron TRA tuvieron una mayor mortalidad precoz (p = 0,003). La única variable relacionada con la mortalidad global de forma independiente fue la puntuación en la NIHSS basal (odds ratio = 1,282; intervalo de confianza al 95%: 1,023-1,608; p = 0,031). Conclusiones. La HIC-ACO presenta una elevada mortalidad, relacionada con la toma de acenocumarol y de forma independiente con la situación clínica inicial. Se comprobó una menor tasa de mortalidad precoz entre pacientes que recibieron TRA.

[Design of a set of indicators for 'Do Not Do' recommendations]. / Diseño de un conjunto de indicadores sobre recomendaciones de «No Hacer¼.

BACKGROUND: There is a growing interest in the optimisation of health care that has fostered and developed initiatives advocating more efficient and safe health care. OBJECTIVE: To determine indicators set for assessing the 'Do Not Do' Recommendations (DNDR) in a Spanish health area, in order to set interventions in motion for improving the quality of care and the patient safety. METHOD: The DNDR published by the health care organisation in 2016 were identified, and those that could be analysed were designed and tested using two assessment methods (if possible, directly from the whole data or, if not, by applying the lot quality assurance sampling - LQAS) and 2016 data from a Spanish health area. Both validity and reliability of these indicators were checked. RESULTS: Of the 271 DNDR identified, 25 (9.3%) were prioritised and their corresponding quality indicator designed. From them, 80% were obtained directly, whereas the rest required LQAS. The interobserver agreement was very high. Efficiency was the quality dimension most frequently involved. CONCLUSIONS: In order to improve the quality of care in terms of adequacy, safety, and sustainability, to assess the DNDR is possible, compulsory, and urgent. Thus, a set of valid, reliable and useful indicators has been designed. This set is focused on identifying improve opportunities and making it possible to approach them.

[Prevention of thromboembolic disease in elderly patients admitted to medical wards]. / Adecuación de la profilaxis tromboembólica en pacientes de edad avanzada hospitalizados en servicios médicos de un hospital de tercer nivel.

OBJECTIVES: To determine the suitability of the prevention of thromboembolic disease in elderly patients admitted to medical departments, as well as some associated factors, such as the measures required in order to improve quality and safety. PATIENTS AND METHODS: A retrospective study in a tertiary level hospital that included elderly patients that were admitted to medical departments. A simple, non-proportional, randomised sample was used, stratified by department. The risk was measured using the Padua prediction model and the risk assessment model of the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) adjusting depending on the number of discharges. A Lot Quality Assurance Sampling (LQAS) plan was used with three levels, good, (standard 95%, threshold 70%), acceptable (standard 95%, threshold 50%), and not acceptable. RESULTS: A total of 72 cases from 8 departments were evaluated. Just over half (51.4%) of patients had a high risk of thromboembolic disease (Padua≥4), and 23.6% of bleeding (IMPROVE≥7). Besides the advanced age, the adjusted scores were particularly due to cancer (22%) and reduced mobility (19%) for Padua, and male gender (13%) and renal failure (12%) for IMPROVE. The adjusted overall suitability was 57.5% (95%CI: ±19.0%). The OR for suitable conduct on not starting medication, 1.56 (95%CI: 1.07-2.26). The suitability by department was not uniform: all the lots were acceptable, in 3 with level "good" and in 5 with "acceptable". CONCLUSIONS: The suitability of thromboembolic prophylaxis in the study hospital maintains acceptable levels, although not homogeneous. There is an opportunity for improvement that must be taken. The data obtained may help in deciding interventions, with LQAS being useful to optimise the evaluation effort.

Impact of an influenza vaccine educational programme on healthcare personnel.

Influenza vaccination has been shown to be the most effective preventive strategy to reduce influenza-related morbidity and mortality in high-risk groups. Despite healthcare personnel (HCP) being considered part of such high-risk groups, their vaccination coverage is low in Europe. In January 2012, we distributed an 18-question survey regarding influenza vaccination to HCP at Gregorio Marañon Paediatric Hospital, in Madrid, Spain. After we documented that only ~30% of HCP were vaccinated an educational programme was implemented in October 2012 before the next influenza season. In January 2013, the same survey delivered again to all HCP documented a significant increase in vaccination rates (from 30% to 40%, P = 0·007) mainly among physicians and for patients' protection. In summary we found that a simple and inexpensive educational programme significantly improved the uptake of influenza vaccination in HCP in our centre. Nevertheless, vaccination rates remained low, and broader and updated campaigns are needed to overcome perception barriers.

Pólipo antropilórico en la enfermead de Menkes / Antropyloric polyp in Menkes disease

Presentamos el caso de un lactante diagnosticado de enfermedad de Menkes en tratamiento sustitutivo con cobrehitidina que presentó un cuadro de pseudoobstrucción instestinal con hemorragia digestiva alta. La aparición de pólipos gastrointestinales por hiperplasia mucosa en la enfermedad de Menkes puede asociar importante morbimortalidad y no se previenen con el tratamiento enzimático, precisando resección endoscópica o quirúrgica (AU)

We present a case of an infant with Menkes disease treated with copper-histidine replacement therapy who developed an intestinal pseudo-obstruction with upper gastrointestinal mucosa and polyps is related to significant morbidity in Menkes disease. We can not prevent them with enzyme treatment so it usually need endoscopic or surgical resection (AU)

Evaluación del riesgo de fenómenos trombóticos tras el uso de factor VII activado / Risk assessment of thrombotic events after the use of activated factor VII

Introducción: El objetivo del estudio fue analizar la incidencia de efectos trombóticos relacionada con la administración de factor VII humano recombinante activo (rFVIIa) en el tratamiento de la hemorragia grave tras la cirugía cardiaca. Material y métodos: Estudio retrospectivo de casos-controles pareado, de 2 años de duración, que incluyó a 72 niños ingresados en cuidados intensivos y tratados con rFVIIa por una hemorragia grave, durante o tras la cirugía cardiaca. Utilizamos un grupo control de 63 pacientes, estadísticamente comparables en cuanto a sexo, peso, diagnóstico, riesgo quirúrgico según la clasificación RACHS-1 y las características quirúrgicas. Resultados: No existieron diferencias significativas en la incidencia de fenómenos trombóticos (20% en casos y 28% en controles, p = 0,540), ni en la mortalidad (16% en casos y 9,5% controles, p = 0,208). Conclusión: En nuestra serie, el tratamiento con rFVIIa ha demostrado ser útil en el control de la hemorragia incoercible en niños sometidos a cirugía cardiaca, y no parece aumentar el riesgo de fenómenos trombóticos ni la mortalidad en el periodo postoperatorio (AU)

Introduction: The objective of this study was to analyze the incidence of thrombotic complications related to recombinant human factor VII a (rFVIIa) therapy for severe postoperative bleeding in cardiac surgery. Material and methods: A retrospective matched case-control study was conducted over two years, including 72 children admitted to intensive care unit and treated with rFVIIa because of a severe bleeding during or after cardiac surgery. A control group of 63 patients was chosen, who were statistically comparable in sex, weight, diagnosis, surgical risk according RASCH-1 score, and surgical characteristics, was chosen. Results: There were no significant differences between cases and controls either in the rate of thrombosis (20% vs 28%, P=0.540), or in the mortality rate (16% vs 9.5%, P=0.208). Conclusions: In our study, the rFVIIa therapy was shown to be useful in controlling severe operative bleeding in pediatric cardiac surgery, but does not seem to increase the risk of thrombotic complications or mortality rate in the postoperative period (AU)

Resistencia a hormonas tiroideas y trastorno por déficit de atención e hiperactividad / Resistance to thyroid hormone and attention deficit hyperactivity disorder

No disponible

[Risk assessment of thrombotic events after the use of activated factor VII]. / Evaluación del riesgo de fenómenos trombóticos tras el uso de factor vii activado.

INTRODUCTION: The objective of this study was to analyze the incidence of thrombotic complications related to recombinant human factor viia (rFVIIa) therapy for severe postoperative bleeding in cardiac surgery. MATERIAL AND METHODS: A retrospective matched case-control study was conducted over two years, including 72 children admitted to intensive care unit and treated with rFVIIa because of a severe bleeding during or after cardiac surgery. A control group of 63 patients was chosen, who were statistically comparable in sex, weight, diagnosis, surgical risk according RASCH-1 score, and surgical characteristics, was chosen. RESULTS: There were no significant differences between cases and controls either in the rate of thrombosis (20% vs 28%, P=.540), or in the mortality rate (16% vs 9.5%, P=.208). CONCLUSIONS: In our study, the rFVIIa therapy was shown to be useful in controlling severe operative bleeding in pediatric cardiac surgery, but does not seem to increase the risk of thrombotic complications or mortality rate in the postoperative period.

First-line treatment of advanced ovarian cancer with paclitaxel/carboplatin with or without epirubicin (TEC versus TC)--a gynecologic cancer intergroup study of the NSGO, EORTC GCG and NCIC CTG.

BACKGROUND: The addition of anthracyclines to platinum-based chemotherapy may provide benefit in survival in ovarian cancer patients. We evaluated the effect on survival of adding epirubicin to standard carboplatin and paclitaxel. PATIENTS AND METHODS: We carried out a prospectively randomized phase III study comparing carboplatin plus paclitaxel (TC; area under the curve 5 and 175 mg/m(2)) with the same combination and epirubicin (TEC; 75 mg/m(2) i.v.). Between March 1999 and August 2001, 887 patients with epithelial ovarian, tubal or peritoneal cancer International Federation of Gynecology and Obstetrics stages IIB-IV were randomized to receive either TC (442 patients) or TEC (445 patients). RESULTS: Median time to progression was 16.4 months in the TEC arm and 16.0 months in the TC arm (hazard ratio 0.99; 95% confidence interval [CI]: 0.9-1.2). Median overall survival time was 42.4 months for the TEC arm and 40.2 for the TC arm (hazard ratio 0.96; 95% CI: 0.8-1.1). Grade 3/4 hematologic toxic effects and most grade 3/4 non-hematologic toxic effects were more frequent in the TEC arm. Accordingly, a quality-of-life analysis showed inferiority of TEC versus TC. CONCLUSION: The addition of epirubicin to standard carboplatin and paclitaxel treatment did not improve survival in patients with advanced ovarian, tubal or peritoneal cancer.

Perforación uterina secundaria a una mola invasiva aparecida sobre un coriocarcinoma / Uterine perforation due to a choriocarcinoma progressing to an invasive mole

Dentro de la enfermedad trofoblástica gestacional encontramos el coriocarcinoma, un tumor raro de gran agresividad local y a distancia, a pesar de lo cual presenta una alta tasa de curación. Presentamos el caso de una paciente joven con una perforación uterina y hemoperitoneo, secundario a un coriocarcinoma, surgido a partir de un aborto espontáneo que se transformó en mola invasiva. Tras intervenir quirúrgicamente a la paciente y tras un exhaustivo control, se consiguió la recuperación total de la misma, sin necesidad de añadir quimioterapia a su tratamiento. Realizamos una revisión de la literatura científica analizando los factores de riesgo de coriocarcinoma, sus técnicas diagnósticas y las opciones terapéuticas (AU)

Gestational trophoblastic disease includes choriocarcinoma, a singular and highly aggressive tumor both at local and distant sites. Nevertheless, the recovery rate is high. We report the case of a young patient with uterine perforation and hemoperitoneum secondary to a choriocarcinoma that developed after a spontaneous abortion and progressed to an invasive mole. After surgery and exhaustive follow-up, complete recovery was achieved with no need for chemotherapy. We review the scientific literature and analyze the risk factors for choriocarcinoma, diagnostic techniques and therapeutic options (AU)

Dermatitis artefacta / Dermatitis artefacta

La dermatitis artefacta (DA) es un trastorno facticio con predominio de signos y síntomas de tipo dermatológico. Las lesiones cutáneas suelen ser muy variables, en función del método empleado y de la imaginación de quienes las producen, aunque existen ciertas características comunes. Su diagnóstico es difícil: hay que excluir las enfermedades físicas verdaderas y se basa en la morfología de las lesiones y en los rasgos de personalidad del paciente. El tratamiento también es complicado; es importante identificar de forma precoz el trastorno y tratar la patología psiquiátrica existente. Presentamos el caso de un niño con un cuadro de DA en forma de lesiones purpúricas (AU)

Dermatitis artefacta (DA) is a factitious disorder in which dermatological signs and symptoms are the predominant feature. Skin lesions are very variable, depending on the methods they choose to use and the imagination of their perpetrators but there are some common characteristics. Its diagnosis is difficult, and it can only be made after excluding real physical illness, based on the morphology of the lesions and the patient’s personality characteristics. The treatment is also complicated but it is important to identify the disorder in an early stage and to treat the underlying psychiatric disorders (AU)

Bronquiectasias en pacientes sin fibrosis quística / Bronchiectasis in patients without cystic fibrosis

Presentamos un caso de neumonías de repetición en la misma localización en una niña de 9 años con tos productiva prácticamente diaria. La prueba del sudor fue negativa y la TC de tórax evidenció bronquiectasias localizadas. Las bronquiectasias son la secuela final de un proceso crónico originado por múltiples causas, la mayoría de ellas adquiridas. Aunque su frecuencia se ha reducido en los últimos años, hay que pensar en ellas ante la cronificación y/o recurrencia de algunas patologías respiratorias. Se analiza su etiología, sus síntomas y signos más frecuentes, así como las pruebas complementarias a realizar. El manejo ideal es el específico de la causa subyacente aunque en pocos casos es posible. Se insiste en el tratamiento médico intensivo, reservándose la cirugía en caso de mala respuesta al mismo (AU)

We present a case of repeated pneumonias in the same location in a 9-year old girl with almost daily productive cough. The sweat test was negative and the chest CT scan showed localized bronchiectasis. Bronchiectases are the final sequel of a chronic process originated by multiple causes, most of them acquired. Although their frequency has decreased in recent years, they must be considered when the condition becomes chronic and/or there is recurrence of some respiratory conditions. An analysis is made of its etiology, most frequent symptoms and signs and the complementary test to be conducted. The ideal management is that specific to the underying cause although this is only possible in a few cases. The need for intensive medical treatment is stressed, reserving surgery for when there is poor response to it (AU)