Safety Management of a Clinical Process Using Failure Mode and Effect Analysis: Continuous Renal Replacement Therapies in Intensive Care Unit Patients.

The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases: 1) Retrospective observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p < 0.05); less patients suffered circuit coagulation with inability to return the blood to the patient (25 patients [46.3%] vs. 16 patients [22.2%]; p < 0.05); 54 patients (100%) versus 5 (6.94%) did not get phosphorus levels monitoring (p < 0.05); in 14 patients (25.9%) versus 0 (0%), the CRRT prescription did not appear on medical orders. As a measure of improvement, we adopt a dynamic dosage management. After the process FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.

Physical and Mechanical Evaluation of Five Suture Materials on Three Knot Configurations: An in Vitro Study.

The aim of this study was to evaluate and compare the mechanical properties of five suture materials on three knot configurations when subjected to different physical conditions. Five 5-0 (silk, polyamide 6/66, polyglycolic acid, glycolide-e-caprolactone copolymer, polytetrafluoroethylene) suture materials were used. Ten samples per group of each material were used. Three knot configurations were compared A.2=1=1 (forward⁻forward⁻reverse), B.2=1=1 (forward⁻reverse⁻forward), C.1=2=1 (forward⁻forward⁻reverse). Mechanical properties (failure load, elongation, knot slippage/breakage) were measured using a universal testing machine. Samples were immersed in three different pH concentrations (4,7,9) at room temperature for 7 and 14 days. For the thermal cycle process, sutures were immersed in two water tanks at different temperatures (5 and 55 °C). Elongation and failure load were directly dependent on the suture material. Polyglycolic acid followed by glycolide-e-caprolactone copolymer showed the most knot failure load, while polytetrafluoroethylene showed the lowest (P < 0.001). Physical conditions had no effect on knot failure load (P = 0.494). Statistically significant differences were observed between knot configurations (P = 0.008). Additionally, individual assessment of suture material showed statistically significant results for combinations of particular knot configurations. Physical conditions, such as pH concentration and thermal cycle process, have no influence on suture mechanical properties. However, knot failure load depends on the suture material and knot configuration used. Consequently, specific suturing protocols might be recommended to obtain higher results of knot security.

Compliance with recommendations on outpatient antibiotic prescribing for respiratory tract infections: the case of Spain.

Inappropriate antibiotic use in primary care, such as in respiratory tract infections (RTIs), is an important cause of bacterial resistance. This study aimed at describing the current pattern of outpatient antibiotic use in acute RTIs in Spain and evaluating adherence to national recommendations. A retrospective observational study was performed including all the episodes of RTIs registered during a 1-year period in a north-eastern Spanish region. Data related to patient demography, diagnoses and antibiotic prescriptions were collected from the electronic medical history database in the region, and adherence to recommendations for antibiotic prescribing was assessed. One third of patients with a RTI were prescribed an antibiotic, with young adults (aged 15-64 years) being the most treated. High prescribing rates were observed in patients with acute otitis, sinusitis and acute tonsillitis (about 70%), whereas low rates were found in acute bronchitis (50%) and non-specific upper RTIs (24%) episodes. A high prescription of broad-spectrum agents and antibiotics not recommended as first choice was observed. In accordance with Spanish guidelines, there exists a potential over-prescribing of antibiotics for all the diagnoses studied, especially in the adult population. Moreover, the choice of antibiotics is frequently based on agents with a high risk of increasing antimicrobial resistance. Multifaceted strategies should be implemented to improve the quality of antibiotic prescribing in primary care.

Acute stress response in gilthead sea bream (Sparus aurata L.) is time-of-day dependent: Physiological and oxidative stress indicators.

Since fish show daily rhythms in most physiological functions, it should not be surprising that stressors may have different effects depending on the timing of exposure. In this study, we investigated the influence of time of day on the stress responses, at both physiological and cellular levels, in gilthead sea bream (Sparus aurata L.) submitted to air exposure for 30 s and then returned to their tank. One hour after air exposure, blood, hypothalamus and liver samples were taken. Six fish per experimental group (control and stressed) were sampled every 4 h during a 24-h cycle. Fish were fed in the middle of the light cycle (ML) and locomotor activity rhythms were recorded using infrared photocells to determine their daily activity pattern of behaviour, which showed a peak around feeding time in all fish. In the control group, cortisol levels did not show daily rhythmicity, whereas in the stressed fish, a daily rhythm of plasma cortisol was observed, being the average values higher than in the control group, with increased differences during the dark phase. Blood glucose showed daily rhythmicity in the control group but not in the stressed one which also showed higher values at all sampling points. In the hypothalamus of control fish, a daily rhythm of corticotropin-releasing hormone (crh) gene expression was observed, with the acrophase at the beginning of the light phase. However, in the stressed fish, this rhythm was abolished. The expression of crh-binding protein (crhbp) showed a peak at the end of the dark phase in the control group, whereas in the stressed sea bream, this peak was found at ML. Regarding hepatic gene expression of oxidative stress biomarkers: (i) cytochrome c oxidase 4 showed daily rhythmicity in both control and stressed fish, with the acrophases located around ML, (ii) peroxiredoxin (prdx) 3 and 5 (prdx5) only presented daily rhythmicity of expression in the stressed fish, with the acrophase located at the beginning of the light cycle and (iii) uncoupling protein 1 showed significant differences between sampling points only in the control group, with significantly higher expression at the beginning of the dark phase. Taken together, these results indicate that stress response in gilthead sea bream is time-dependent as cortisol level rose higher at night, and that different rhythmic mechanisms interplay in the control of neuroendocrine and cellular stress responses.

Estimating kidney function in the critically ill patients.

Glomerular filtration rate (GFR) is an accepted measure for assessment of kidney function. For the critically ill patient, creatinine clearance is the method of reference for the estimation of the GFR, although this is often not measured but estimated by equations (i.e., Cockroft-Gault or MDRD) not well suited for the critically ill patient. Functional evaluation of the kidney rests in serum creatinine (Crs) that is subjected to multiple external factors, especially relevant overhydration and loss of muscle mass. The laboratory method used introduces variations in Crs, an important fact considering that small increases in Crs have serious repercussion on the prognosis of patients. Efforts directed to stratify the risk of acute kidney injury (AKI) have crystallized in the RIFLE or AKIN systems, based in sequential changes in Crs or urine flow. These systems have provided a common definition of AKI and, due to their sensitivity, have meant a considerable advantage for the clinical practice but, on the other side, have introduced an uncertainty in clinical research because of potentially overestimating AKI incidence. Another significant drawback is the unavoidable period of time needed before a patient is classified, and this is perhaps the problem to be overcome in the near future.

Prevalence of acute kidney injury in intensive care units: the "COrte de prevalencia de disFunción RenAl y DEpuración en críticos" point-prevalence multicenter study.

PURPOSE: This study aimed to measure the point prevalence of kidney dysfunction (KD) in the intensive care setting. MATERIALS AND METHODS: A point-prevalence, single-day, prospective study was conducted. Of 919 patients present in 42 Intensive care units (ICUs) for 2 specific days (September 2009 and March 2010), 832 cases were included. Mild KD was defined as a measured creatinine clearance of 90 to 60 mL min(-1) 1.73 m(-2), and severe KD was defined as a creatinine clearance less than 60 mL min(-1) 1.73 m(-2). RESULTS: Prevalence of mild KD was 15.9/100 patients/d (13.5-18.5), and severe KD was 42.4/100 patients/d (39.1-45.8). We considered as having a low probability of experiencing KD those patients without chronic kidney disease, acute kidney injury network stage 0, and a serum creatinine less than 1.2 mg/dL, but among them (557 patients), 18.1% (15.2%-21.6%) had mild KD and 24.2% (20.9%-28%) had severe KD. ICU mortality was 10.6% (7.81%-14.4%) for patients without dysfunction, 16.6% (11.2%-24%) for patients with mild KD, and 29.7% (25.2%-34.7%; P<.001) for patients with severe KD, with a relative risk for severe KD vs no KD of 2.54 (1.90-3.40). In 54.3% patients, at least 1 renal insult was reported. One nephrotoxic drug was administered to 34.4% and 2 or more to 14.9% patients, with a lower frequency among those with chronic kidney disease (30.6% vs 50.8%; P<.05). CONCLUSIONS: Each day of study, more that half of the patients admitted to the ICU showed some derangement in kidney function. More than 25% of patients not fulfilling the KD criteria by serum creatinine or acute kidney injury network showed, in fact, a severe KD, and this finding was associated with higher mortality. More than 50% of the patients admitted to the ICU were subjected to at least 1 renal insult.

The effect of an 810-nm diode laser on postoperative pain and tissue response after modified Widman flap surgery: a pilot study in humans.

BACKGROUND: The purpose of this single-masked pilot clinical study is to compare the tissue response and postoperative pain after the use of a diode laser (810 nm) (DL) as an adjunct to modified Widman flap (MWF) surgery to that of MWF alone. METHODS: Thirteen patients with generalized severe chronic periodontitis completed the study. Control sites were randomly selected to receive an MWF and the contralateral test sites an MWF in conjunction with a DL. The study tooth/site was treated plus any additional teeth in the quadrant in which the site was located, if needed. Randomization was done using a coin flip. The DL was used to de-epithelialize the inner part of the periodontal flap and photo-biostimulate the surgical area. Pain scale assessment (PS), pain medication consumption (PM), tissue edema (TE), and tissue color (TC) were evaluated 1 week after surgery. RESULTS: Statistically significant differences were seen for TE (P = 0.041), PM (P <0.001), and PS (P <0.001) favoring test sites. TC did not show a statistically significant difference (P = 0.9766). Patients rated the first surgical treatment (test or control; random assignment to first treatment) performed as more painful than the second (P <0.002). CONCLUSION: The use of an 810-nm diode laser provided additional benefits to MWF surgery in terms of less edema and postoperative pain.

In vitro evaluation of the root surface microtopography following the use of two polishing systems by Confocal Microscopy (CFM) and Scanning Electron Microscope (SEM).

OBJECTIVES: To compare and evaluate the root surface roughness after using two polishing instruments for root planing. MATERIALS AND METHODS: This comparative study was carried out on a sample of ten extracted human teeth with twenty interproximal root surfaces. Control group 1 and 2: (n=20 root surface): Gracey Curettes, 15 vertical strokes. Test group 1 (n=10): control group 1 + Termination Diamond Curettes (TDC), 15 strokes. Test group 2 (n=10): control group 2 + Termination Diamond Burs -15 µm (TDB), with irrigation for 15 seconds at 3000 rpm. The root surface was planed with the polishing instruments and test measurements were obtained with Confocal Microscopy (CFM) and Scanning Electron Microscope (SEM). The primary outcome variable was surface roughness (Ra). RESULTS: CFM showed that the TDC, mean changes in surface roughness (Ra) were reduced by 0.11 ± 0.14 (p-value = 0.000), and the TDB, Ra: were reduced by 0.27 ± 0.86 (p-value = 0.037). Non-statistically significant differences were observed in Ra (p-value = 0.581) between the two polishing instruments. SEM showed that the Group 2 showed a generally rougher surface with more parallel grooves than Group 1. CONCLUSION: There are no statistically significant differences between these two polishing systems, although TDB seems to reduce the surface roughness more than the TDC after being treated with Gracey Curettes.

Subepithelial connective tissue graft in combination with a coronally advanced flap for the treatment of Miller Class II and III gingival recessions in mandibular incisors: a case series.

Limited evidence is available regarding the effect of the subepithelial connective tissue graft (SCTG) on root coverage in the mandibular anterior region. A technique is described using an SCTG with a coronally advanced flap (CAF) for the treatment of Miller Class II and III gingival recessions in mandibular central incisors. Fourteen Miller Class II and III recessions were treated in 10 patients using an SCTG with a CAF. After a mean follow-up of 11.7 months, 90.22% ± 12.36% root coverage was achieved. There were no statistically significant differences in root coverage for Miller Class II and III recession defects. Complete root coverage was achieved at five (71.42%) Miller Class II sites compared with three (42.85%) Class III defects. These results suggest that the combination of an SCTG and CAF is an effective technique to obtain root coverage in mandibular incisors with Class II and III recession defects, with excellent patient satisfaction regarding the esthetic appearance of the treated teeth.

Relación entre los médicos y la industria en Aragón (España) / Relationship between physician and industry in Aragon (Spain)

Objetivo Describir, en Aragón, la relación entre los médicos y la industria, y analizar las características de los médicos que se asocian con la probabilidad de recibir beneficios. Métodos Estudio transversal en el cual médicos aragoneses del sector público y privado rellenaron un cuestionario anónimo en una página web, entre junio y noviembre de 2008. El número de visitas/mes con la industria, muestras, regalos, dietas y pagos se incluyeron como variables dependientes en los modelos de regresión. Las variables año de licenciatura, especialidad, lugar de trabajo, tiempo de atención, artículos leídos/mes y ser tutor de residentes se utilizaron como variables independientes. Resultados Se consideraron válidos 659 cuestionarios completados. En general, el 87% de los que respondieron contestaron que habían recibido algún beneficio en el último año, y un 90,1% (n=593) respondieron que habían tenido alguna entrevista con representantes de la industria mensualmente. Las especialidades no clínicas recibieron menos regalos (odds ratio [OR]=0,38; intervalo de confianza del 95% [IC95%]: 0,18-0,77), dietas (OR=0,14; IC95%: 0,06-0,35) y pagos (OR=0,30; IC95%: 0,13-0,74) que sus colegas clínicos. La probabilidad de recibir dietas (OR=0,37; IC95%: 0,15-0,89) y pagos (OR=0,39; IC95%: 0,20-0,77) fue menos probable para los médicos de atención primaria. Conclusiones Este estudio muestra diferencias en la intensidad de la relación médico-industria en función de la especialidad y el lugar de trabajo del médico. Esta información se considera importante para mejorar la transparencia y para desarrollar investigaciones futuras sobre la adecuación y la eficiencia de la prescripción en nuestro país y en otros con sistemas sanitarios similares(AU)

Objective To describe the relationship between industry and physicians and to analyze the physician characteristics associated with the probability of receiving benefits from industry in Aragon (Spain).Methods We carried out an observational, cross-sectional study in which Aragonese physicians (north-east region in Spain) from public and private settings completed an anonymous questionnaire on a web page between June and November 2008. Visits/month with industry, samples, gifts, reimbursements and payments were used as dependant variables in the regression analyses. Year of medical license, specialty, work setting, time spent on direct care, articles read/month and being a resident's tutor were used as independent variables. Results A total of 659 questionnaires were considered valid for the analysis. Overall, 87% (n=573) of the respondents reported they had received some benefit in the previous year and 90.1% (n=593) reported having held meetings with industry representatives monthly. Non-clinical specialists received fewer gifts (odds ratio [OR]=0.38; 95% confidence interval [95%CI]: 0.18-0.77), reimbursements (OR=0.14; 95%CI: 0.06-0.35) and payments (OR=0.30; 95%CI: 0.13-0.74) than their clinical colleagues. The probability of receiving reimbursements (OR=0.37; 95%CI: 0.15-0.89) and payments (OR=0.39; 95%CI: 0.20-0.77) was lower in primary care physicians. Conclusions This study, performed in a sample of physicians from a southern European region, demonstrates differences in the intensity of the physician-industry relationship depending on physician specialty and work setting. These results provide important information for improving transparency and for future research on the appropriateness and efficiency of prescription in Spain and other countries with similar health systems(AU)

Relationship between physician and industry in Aragon (Spain).

OBJECTIVE: To describe the relationship between industry and physicians and to analyze the physician characteristics associated with the probability of receiving benefits from industry in Aragon (Spain). METHODS: We carried out an observational, cross-sectional study in which Aragonese physicians (north-east region in Spain) from public and private settings completed an anonymous questionnaire on a web page between June and November 2008. Visits/month with industry, samples, gifts, reimbursements and payments were used as dependant variables in the regression analyses. Year of medical license, specialty, work setting, time spent on direct care, articles read/month and being a resident's tutor were used as independent variables. RESULTS: A total of 659 questionnaires were considered valid for the analysis. Overall, 87% (n=573) of the respondents reported they had received some benefit in the previous year and 90.1% (n=593) reported having held meetings with industry representatives monthly. Non-clinical specialists received fewer gifts (odds ratio [OR]=0.38; 95% confidence interval [95%CI]: 0.18-0.77), reimbursements (OR=0.14; 95%CI: 0.06-0.35) and payments (OR=0.30; 95%CI: 0.13-0.74) than their clinical colleagues. The probability of receiving reimbursements (OR=0.37; 95%CI: 0.15-0.89) and payments (OR=0.39; 95%CI: 0.20-0.77) was lower in primary care physicians. CONCLUSIONS: This study, performed in a sample of physicians from a southern European region, demonstrates differences in the intensity of the physician-industry relationship depending on physician specialty and work setting. These results provide important information for improving transparency and for future research on the appropriateness and efficiency of prescription in Spain and other countries with similar health systems.

Tratamiento de la enfermedad periodontal agresiva. A propósito de un caso / No disponible

La enfermedad periodontal agresiva suele producirse en pacientes jóvenes, sistémicamente sanos, en los que se observa una agregación familiar y la pérdida de inserción y ósea son rápidas. Este tipo de enfermedad puede estar causada por un componente bacteriano, genético y ambiental. El tratamiento periodontal puede ser igual de efectivo en esta forma de la enfermedad. Sin embargo, debido a la importante susceptibilidad de estos pacientes, es esencial la motivación en el cuidado de la higiene oral y en el cumplimiento delos mantenimientos periodontales (AU)

Aggressive Periodontitis is usually seen in young patients, systemically healthy, with a familial aggregation and a rapid rate of attachment and bone loss. It may be caused by a bacterial, genetic and environmental component. Periodontal treatment is as effective as in other periodontal pathologies. However, oral hygiene compliance and periodontal recallsare important due to the high susceptibility of these patients (AU)

[Is it pertinent to investigate the relations between physicians and the drug industry]. / Es pertinente investigar las relaciones entre médicos e industria farmacéutica?

OBJECTIVE: To analyse the opinions of physicians on the appropriateness of research into the relationships between doctors and pharmaceutical industry, and to evaluate the usefulness of email survey in this research. MATERIAL AND METHODS: Survey via email of 373 authors of papers published in Spanish medical journals in 2007. The relationships between doctors and the industry was measured by asking doctors what they had received from industry during last year, the value in euro, and the number of visits from industry representatives. RESULTS: The response rate was 28.2%. Most physicians (90.5%) considered the study appropriate. Only 3.2% of doctors refused to take part in the study due to disagreeing with methodology. A total of 92.8% received something from industry during last year (62% cost associated with professional meetings, 60% material for continuing medical education). Mean value of gifts received was 900 euro (60-12,000 euro). By sex, women apparently received more drug samples, and men more payments for consulting or enrolling patients in trials. Doctors practicing in hospitals seemed to receive more gifts than primary care doctors, particularly trips or lunch. Number of visits of industry representatives (from 5 to 10 weekly) was associated with more gifts to doctors. CONCLUSIONS: The vast majority of doctors agree with the appropriateness of researching into the relationships between doctors and the pharmaceutical industry. Relationships between physicians and industry appear to be intensive, as seen in other studies. Response rate was low, but the simplicity and speed of the method are valuable advantages.

¿Es pertinente investigar las relaciones entre médicos e industria farmacéutica? / No disponible

Fundamento y objetivo: Analizar la opinión de los médicos sobre la pertinencia de investigar las relaciones médico-industria farmacéutica, y explorar la utilidad de la encuesta realizada por correo electrónico. Material y métodos: Encuesta vía correo electrónico a 373 médicos autores de artículos en revistas médicas españolas en 2007. El estudio consta de 5 preguntas adaptadas de una encuesta realizada en EE.UU. con el mismo objetivo. Las variables de la encuesta son: tipo de ayudas que los médicos habían recibido de la industria en el último año, el valor en euros de dichas ayudas, y cuántas visitas recibieron de representantes de la industria. Resultados: La tasa de respuesta fue del 28,2%. El 90,5% de los médicos consideró pertinente el estudio. El 3,2% rechazó participar por desacuerdo con la metodología. El 92,8% afirmó haber recibido algo de la industria en el último año (el 62% inscripción a congresos viajes, el 60% material de formación continuada). Los médicos estimaron en valor medio de lo recibido en 900 € (60-12.000€). Con la cautela debidas a la tasa de respuesta y la muestra de conveniencia, aparecen algunas diferencias por sexo; las mujeres responden que reciben más muestras gratuitas, y los varones más honorarios por trabajo o por incluir pacientes en ensayos. También hay diferencias no significativas por ámbito de trabajo: los médicos de hospitales indican que reciben más ayudas que los de atención primaria, sobre todo viajes a congresos e invitaciones en restaurantes. El número de visitas de representantes (5-10 por semana) se asocia con mayor percepción de ayudas. Conclusiones: La gran mayoría de los médicos que responden a la encuesta consideran adecuado investigar las relaciones entre médicos e industria. Los datos sugieren que la relación entre médicos e industria es intensa, de forma concordante con otros trabajos publicados (AU)

Objective: To analyse the opinions of physicians on the appropriateness of research into the relationships between doctors and pharmaceutical industry, and to evaluate the usefulness of email survey in this research Material and methods: Survey via email of 373 authors of papers published in Spanish medical journals in 2007. The relationships between doctors and the industry was measured by asking doctors what they had received from industry during last year, the value in€, and the number of visits from industry representatives. Results: The response rate was 28.2%. Most physicians (90.5%) considered the study appropriate. Only 3.2% of doctors refused to take part in the study due to disagreeing with methodology. A total of 92.8% received something from industry during last year (62%cost associated with professional meetings, 60% material for continuing medical education). Mean value of gifts received was 900 € (60-12,000 €). By sex, women apparently received more drug samples, and men more payments for consulting or enrolling patients intrials. Doctors practicing in hospitals seemed to receive more gifts than primary care doctors, particularly trips or lunch. Number of visits of industry representatives (from 5 to 10 weekly) was associated with more gifts to doctors. Conclusions: The vast majority of doctors agree with the appropriateness of researching into the relationships between doctors and the pharmaceutical industry. Relationships between physicians and industry appear to be intensive, as seen in other studies. Response rate was low, but the simplicity and speed of the method are valuable advantages (AU)

Elaboración de un método para clasificar y analizar las sugerencias de los pacientes / Design of a method to classify and analyze patients´ suggestions

Objetivos: Crear un sistema eficiente para clasificar las sugerencias de los pacientes y analizar los comentarios recibidos entre junio de 2002 y octubre de 2003.Material y métodos: Se obtienen las sugerencias de una pregunta abierta. Inicialmente, se agrupan los comentarios en 3 tipos: queja, agradecimiento o sugerencia. Posteriormente, se los clasifica en 4 categorías: a) estructura; b) organización y tiempos de espera; c) información y práctica clínica, y d) atención recibida y trato del personal, diferenciando códigos específicos para cada categoría. En el estudio de concordancia se cuantificó el índice kappa y su significación estadística. Posteriormente se analizaron los comentarios de las encuestas recibidas durante 15 meses. Resultados: Se seleccionaron aleatoriamente 200 encuestas, que recogieron 122 comentarios. La concordancia en la clasificación del tipo de sugerencia fue evaluada en 101 casos, con una incidencia de casos coincidentes del 77,2 por ciento, y un índice kappa de 0,664 (p < 0,0001). Para la concordancia entre categorías, se evaluaron 89 casos, con una coincidencia del 84,3 por ciento y un índice kappa de 0,782 (p < 0,0001). En el análisis, descubrimos que el principal motivo de comentario hace referencia al trato recibido por el paciente. Según el tipo, la queja más frecuente fue la falta de información; el motivo de agradecimiento, el trato recibido, y la sugerencia, la comodidad del paciente. Conclusiones: Este sistema de clasificación es consistente, y observadores diferentes lo realizan de forma similar. La codificación de las sugerencias facilita su análisis para captar qué necesita el ciudadano del sistema sanitario que le atiende (AU)

El uso del método epidemiológico para la evaluación de la calidad de la asistencia (II) / Use of the epidemiological method to evaluate health care quality (II)

No disponible

El uso del método epidemiológico para la evaluación de la calidad de la asistencia (I) / Use of the epidemiological method to evaluate health care quality (I)

No disponible