Mineralcorticoid receptor blockers in chronic kidney disease.

There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage. Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin-angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events. In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent/decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers. The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits. Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.

[Mineralcorticoid receptor blockers in chronic kidney disease]. / Bloqueantes del receptor mineralcorticoide en la enfermedad renal crónica.

There are many experimental data supporting the involvement of aldosterone and mineralcorticoid receptor (MR) activation in the genesis and progression of chronic kidney disease (CKD) and cardiovascular damage. Many studies have shown that in diabetic and non-diabetic CKD, blocking the renin- angiotensin-aldosterone (RAAS) system with conversion enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) decreases proteinuria, progression of CKD and mortality, but there is still a significant residual risk of developing these events. In subjects treated with ACEi or ARBs there may be an aldosterone breakthrough whose prevalence in subjects with CKD can reach 50%. Several studies have shown that in CKD, the aldosterone antagonists (spironolactone, eplerenone) added to ACEi or ARBs, reduce proteinuria, but increase the risk of hyperkalemia. Other studies in subjects treated with dialysis suggest a possible beneficial effect of antialdosteronic drugs on CV events and mortality. Newer potassium binders drugs can prevent / decrease hyperkalemia induced by RAAS blockade, and may reduce the high discontinuation rates or dose reduction of RAAS-blockers. The nonsteroidal MR blockers, with more potency and selectivity than the classic ones, reduce proteinuria and have a lower risk of hyperkalemia. Several clinical trials, currently underway, will determine the effect of classic MR blockers on CV events and mortality in subjects with stage 3b CKD and in dialysis patients, and whether in patients with type 2 diabetes mellitus and CKD, optimally treated and with high risk of CV and kidney events, the addition of finerenone to their treatment produces cardiorenal benefits. Large randomized trials have shown that sodium glucose type 2 cotransporter inhibitors (SGLT2i) reduce mortality and the development and progression of diabetic and nondiabetic CKD. There are pathophysiological arguments, which raise the possibility that the triple combination ACEi or ARBs, SGLT2i and aldosterone antagonist provide additional renal and cardiovascular protection.

Implante de un dispositivo de asistencia ventricular izquierda definitivo y circulación asistida en cuidados intensivos como terapia puente. Cuidados enfermeros: caso clínico / Permanent left ventricular assistance internal device implantation and assisted circulation in intensive care as bridge therapy. Nursing care: case report

A lo largo de los últimos años la implantación de Dispositivos de Asistencia Ventricular (DAV) está tomando un papel más relevante en el tratamiento de la Insuficiencia Cardíaca (IC). El uso de los DAV también está cambiando hacia la Terapia Definitiva (TD), conformándose como alternativa clara al trasplante cardíaco. La implantación de un DAV, en ocasiones, requiere previamente tratamiento emergente con otros dispositivos de Asistencia Circulatoria Mecánica (ACM) como Circulación Extracorpórea con Membrana de Oxigenación (ECMO) o Asistencia Ventricular paracorpórea Izquierda o Derecha. Por tanto, es necesario el ingreso en Unidades de Cuidados Intensivos (UCI) especializadas en estas terapias hasta la estabilización del paciente y toma de la decisión correcta. Se expone un caso clínico reciente de una persona que requiere asistencia inicial con ECMO V-A emergente en el hospital de origen y su traslado al centro de referencia para posterior asistencia biventricular paracorpórea e implantación definitiva de un DAVI (Dispositivo de Asistencia Ventricular Izquierda). Se exponen la secuencia de decisiones, complicaciones y el plan de cuidados de enfermería inicial en UCI con taxonomía NANDA. Es el primer implante de un DAVI, realizado en nuestro hospital. En él ha intervenido un enorme equipo multidisciplinar.

Over the past few years, the Ventricular Assist Devices (VADs) implementation is taking a relevant role in the Heart Failure (HF) treatment. VADs ́s use is also shifting towards Definitive Therapy (TD), being a clear alternative to heart transplantation. The implantation of a VAD, sometimes, requires a previous emergent treatment with other Mechanical Circulatory Assistance (ACM) devices such as Extracorporeal Circulation with Oxygenation Membrane (ECMO) or Left or Right Paracorporeal Ventricular Assistance. So is necessary of a mobile team for emergency assistance with ECMO and transfer to Intensive Care Units (ICU) which is specialized in these therapies until the patient stabilizes and doctors takes the right decision. A recent clinical case of a patient is exposed. This person required assistance with emergent ECMO V-A (Venous-Arterial) in the hospital of origin and his transfer to the reference center for subsequent biventricular paracorporeal assistance and to the definitive implantation of LVAD (Left Ventricular Assist Device). The sequence of decisions, complications and the initial nursing care plan at ICU with NANDA taxonomy, are presented here. This is the first implant of a LVAD in our hospital. A huge multidisciplinary team has been involved in the project.

Limitación del esfuerzo terapéutico. Opinión de estudiantes universitarios de Enfermería / Limitation of therapeutic effort. Opinion by Universtity Nursing Students

OBJETIVO: conocer la opinión de los estudiantes de Enfermería sobre la limitación del esfuerzo terapéutico (LET). MÉTODO: estudio descriptivo transversal sobres 97 alumnos de 3º y 4º curso de la Escuela Universitaria de Enfermería Virgen de las Nieves de Granada, mediante el cuestionario anónimo autoadministrado, validado por Llaja Rojas et al. (15). Otras variables: profesión, sexo, estado civil, edad, años de experiencia laboral y religión. Tratamiento y análisis de los datos: análisis descriptivo de las variables y análisis bivariante mediante la prueba Ji Cuadrado. RESULTADOS: el 48,4% se declaraba católico no practicante. Para el 91,8% la decisión de mayor peso en cuanto a la LET la tiene el paciente. En cuanto a la eutanasia, un 88,9% estaba de acuerdo con legalizarla y un 92,5% la aplicaría. El 92,5% de los católicos no practicantes estaban de acuerdo con legalizar la eutanasia, frente al 100% de los no creyentes (p< 0,000). Para un 90,9% de los no creyentes, frente a un 54,5% de los católicos practicantes, no hay calidad de vida si se está conectado a un ventilador mecánico (p= 0,026). CONCLUSIONES: los estudiantes de Enfermería tienen muy en cuenta la opinión del paciente ante la LET. Mayoritariamente están a favor de legalizar la eutanasia y aplicarla, así como la antidistanasia y ortotanasia. Las creencias religiosas tienen influencia sobre algunas de las cuestiones exploradas. Una gran mayoría considera que situaciones como vivir en silla de ruedas, tener colostomía permanente, recibir quimioterapia o tener traqueostomía definitiva, pueden otorgar cierta calidad de vida, mostrando una opinión muy positiva del proceso de enfermedad

OBJECTIVE: to identify what is known about the Spanish Red Cross Nurses-Ladies. METHOD: a historical research was conducted, based on a bibliographic review. Documentary sources: virtual catalogues of libraries and document archives, electronic databases, catalogues of journals specialized in history, and other internet sources. Descriptors used: the History of Nursing, the History of the Spanish Red Cross, Red Cross nurses, Queen Victoria Eugenia of Battemberg, Carmen Angoloti Mesa, Duchess de la Victoria, and Red Cross ladies/nurses/assistants/volunteers. RESULTS: the analysis included 42 documents from studies based on primary sources, and results were presented in five sections: overall historical development, functioning and organization, care and social work, and promoting leading figures. CONCLUSIONS: though there is currently a large volume of studies on the history of Nurses-Ladies, it is necessary to go deeper through new research on some aspects, such as the work they conducted during their career

Prevalence of osteoporotic vertebral fracture in Spanish women over age 45.

The aim of this work is to study the prevalence of osteoporotic vertebral fractures in Spanish women over 45 years of age, based on the selection of a nationwide sample. An observational, cross-sectional, multicenter study was conducted during 2006, in all of Spain's regions. The sample analyzed was of 5000 individuals, representative of the female population over age 45 in Spain. A questionnaire was used to determine which factors are most often associated with vertebral fractures. We also assessed whether the Prevalent Vertebral Fracture Index, proposed by Vogt, is useful in indicating a possible osteoporotic vertebral fracture. Five hundred orthopedic surgeons, from various Spanish regions, were trained in different aspects of the study: inclusion and exclusion criteria, management of the risk factor questionnaire, and implementation of the Vogt questionnaire. The number of fracture cases was 1549 (31.79%). 528 Women (34.08%) had a single vertebral fracture, and 1021 (65.92%) had multiple vertebral fractures. The following factors were statistically significantly associated with vertebral fracture: age, late menarche, early menopause, diabetes mellitus, hyperparathyroidism, rheumatoid arthritis, height loss, daily physical activity, corticosteroid therapy, personal history of osteoporotic fracture and previous diagnosis of osteoporosis. The differences in Vogt score according to age and fracture status were statistically significant. The conclusion of the study is that vertebral osteoporotic fracture in the female Spanish population is frequent. The high prevalence in the Spanish population older than 60 years is probably related to malnutrition in the period from 1936 to 1952.

Complications of hip fractures: A review.

Nowadays, fracture surgery represents a big part of the orthopedic surgeon workload, and usually has associated major clinical and social cost implications. These fractures have several complications. Some of these are medical, and other related to the surgical treatment itself. Medical complications may affect around 20% of patients with hip fracture. Cognitive and neurological alterations, cardiopulmonary affections (alone or combined), venous thromboembolism, gastrointestinal tract bleeding, urinary tract complications, perioperative anemia, electrolytic and metabolic disorders, and pressure scars are the most important medical complications after hip surgery in terms of frequency, increase of length of stay and perioperative mortality. Complications arising from hip fracture surgery are fairly common, and vary depending on whether the fracture is intracapsular or extracapsular. The main problems in intracapsular fractures are biological: vascularization of the femoral head, and lack of periosteum -a major contributor to fracture healing- in the femoral neck. In extracapsular fractures, by contrast, the problem is mechanical, and relates to load-bearing. Early surgical fixation, the role of anti-thromboembolic and anti-infective prophylaxis, good pain control at the perioperative, detection and management of delirium, correct urinary tract management, avoidance of malnutrition, vitamin D supplementation, osteoporosis treatment and advancement of early mobilization to improve functional recovery and falls prevention are basic recommendations for an optimal maintenance of hip fractured patients.

Limitación del esfuerzo terapéutico en cuidados intensivos / Limitation of Therapeutic Effort in Intensive Care

OBJETIVO: explorar la opinión del personal de Enfermería de un servicio de Cuidados Intensivos de un centro hospitalario médico-quirúrgico sobre la limitación del esfuerzo terapéutico. MÉTODO: estudio descriptivo prospectivo, realizado durante los meses de octubre y noviembre de 2013, mediante la cumplimentación de un cuestionario validado autoadministrado. La población de estudio han sido los/las auxiliares y profesionales de Enfermería de la Unidad de Cuidados Intensivos del Hospital Universitario Virgen de las Nieves de Granada. Los criterios de inclusión fueron tener una experiencia mayor a dos años de trabajo en la unidad. Se analizaron las variables sociodemográficas y cualitativas, estudiando con chi-cuadrado posibles asociaciones estadísticas. RESULTADOS: de las 88 personas encuestadas, 58 enfermeras/os y 30 auxiliares, el 72,4% piensa que no es lo mismo no instaurar que retirar una forma de tratamiento ya instaurado, frente al 27,6% que opina que sí es igual. En cuanto a quién debe tomar la decisión de la aplicación de medidas extraordinarias de soporte en enfermedades irrecuperables, el 77% da mayor peso a la decisión del paciente. El 57% ha hecho público su deseo de no recibirlas si estuviera en situación crítica o de terminalidad. Sobre la legalización de la eutanasia, un 71,8% está a favor y un 81,4% la aplicaría en pacientes irrecuperables o en estado agónico si lo hubieran expresado previamente. El 98,9% está a favor de la práctica de la ortotanasia. CONCLUSIONES: cabe destacar la importancia de la existencia del registro de voluntades anticipadas, debiendo fomentarse el uso de dicho registro para evitar los conflictos de intereses, conociendo bien la opinión del paciente. Cuando no se cuente con dicho documento, en caso de conflicto, siempre y cuando el paciente no tenga autonomía para decidir, lo que parece más acertado es la intervención del Comité de Ética Asistencial

OBJECTIVE: to explore the opinion of the Nursing staff in the Intensive Care Unit of a clinical-surgical hospital about the limitation of therapeutic effort. METHOD: prospective descriptive study, conducted during October and November, 2013, through a validated self-completion questionnaire. The study population was the Nursing assistants and professionals from the Intensive Care Unit of the Hospital Universitario Virgen de las Nieves, Granada. The inclusion criteria were experience over two years in said Unit. Socio-demographical and qualitative variables were analyzed, and potential statistical associations were studied with Chi-square Test. RESULTS: out of those 88 persons analyzed, 58 nurses and 30 assistants, a 72.4% thinks that not initiating is not the same as withdrawing treatment already initiated, vs. 27.6% who think that it is the same. Regarding who must make the decision to apply extraordinary support measures in incurable conditions, 77% assigns higher weight to patients' decision. A 57% have made public their wish not to receive them if they were in a critical or end-stage situation. Regarding the legalization of euthanasia, 71.8% are in favour, and 81.4% would apply it in incurable patients or dying situations, if previously expressed. A 98.9% are in favour of orthothanasia. CONCLUSIONS: the importance of the existence of an AdvanceDirective Registry must be pointed out; the use of said registry should be encouraged in order to prevent a conflict of interests, through a clear awareness of the patient's opinion. When this document is not available, in case of conflict, and provided patients are not able to decide on their own, the intervention of the Healthcare Ethics Committee appears as the most adequate solution

Niveles de concordancia interobservador de las escalas Norton y Braden en cuidados críticos / Interobserver concordance degrees in Norton and Braden scales for critical care

Objetivo: analizar la fiabilidad interobservador de cada uno de los ítems que componen las escalas Norton y Braden cuando se utilizan en cuidados intensivos. Material y método: estudio descriptivo multicéntrico en las Unida desde Cuidados Intensivos (UCI) de dos hospitales de Granada, con dos observadores en el Hospital Universitario Virgen de las Nieves (HUVN) y tres en el Hospital Universitario San Cecilio (HUSC) de Granada. Se seleccionaron268 pacientes en HUSC y 215 en HUVN, teniendo en cuenta una proporción de acuerdo esperada de 0,65 y una seguridad del 95%. Para el cálculo de la fiabilidad interobservador se utilizó el coeficiente de Kappa(dos observadores) y Kappa Fleiss (tres observadores). Se calcularon intervalos de confianza para un 95% de seguridad (IC 95%).Resultados: la fiabilidad total interobservador fue Muy Buena para ambas escalas: k= 0,8196 (IC 95%: 0,7350-0,901) para la escala Norton yk= 0,90 (IC 95%: 0,858-0,940) para Braden. En la escala de Norton los ítems Estado Físico e Incontinencia presentaron concordancias Moderada y Débil, el resto entre Buenas-Muy Buenas. En la escala de Braden, elítem Riesgo de Lesiones mostró concordancia Pobre (en HUVN) y Buena(en HUSC); el resto entre Moderadas-Muy buenas. Conclusiones: en ambos centros el ítem Estado físico muestra menos concordancia para la escala Norton. Para la Braden destaca el nivel de Pobre para Riesgo de Lesiones solamente en el centro sanitario que no se usaba habitualmente (menor nivel entrenamiento). La fiabilidad interobservador total de las escalas es mucho mayor que por ítems porque estas estratifican los riesgos (AU)

Objective: to analyze the interobserver reliability of each of the items included in the Norton and Braden Scales, when used in intensive care. Materials and method: multicenter descriptive study in the Intensive Care Units (ICUs) of two hospitals in Granada, with two observers in the Hospital Universitario Virgen de las Nieves (HUVN), and three in the Hospital Universitario San Cecilio (HUSC) in Granada. There was a selection of268 patients in HUSC and 215 in HUVN, taking into account an expected0.65 proportion of agreement, and a 95% safety. The Kappa coefficient was used (two observers) in order to calculate interobserver reliability, aswell as the Kappa Fleiss (three observers). Confidence intervals were calculated for 95% safety (CI 95%).Results: total interobserver reliability was Very Good for both scales: k=0.8196 (CI 95%: 0.7350-0.901) for the Norton Scale and k=0.90 (CI95%: 0.858-0.940) for Braden. Within the Norton Scale, the items Physical Condition and Incontinence showed Moderate and Weak concordances, while the rest ranged between Good- Very Good. Within the Braden Scale, the item Risk of Lesions showed Poor (in HUVN) and Good concordance (in HUSC); the rest ranged between Moderate-Very Good. Conclusions: in both centers, the item Physical Condition shows lower concordance for the Norton Scale. In terms of the Braden Scale, Poor concordance for Risk of Lesions is noticeable only in that health centre where it was not typically used (lower training level).The total interobserver reliability of scales is higher than per items, because there is risk stratification in scales (AU)

Clinical and radiologic features of pigmented villonodular synovitis of the foot: report of eight cases.

Pigmented villonodular synovitis, a rare proliferative disease of unknown etiology, is rare in the foot (2% of these lesions). A retrospective review was undertaken of the case histories, radiographs, and imaging results of eight patients treated for pigmented villonodular synovitis of the foot. Pigmented villonodular synovitis was located in the rearfoot in five patients and in the forefoot in the other three. Radiographs in six patients showed bone involvement. Affected bones included the talus, first cuneiform, first and fifth metatarsals, and second phalanx. Treatment was surgical, and only one recurrence was recorded after 24 months. Pigmented villonodular synovitis should be considered in the differential diagnosis of foot tumors.