[Adequacy of the special category antibiotics prescriptions in the Emergency Department of a third level urban Hospital]. / Adecuación del uso de antibióticos de "Categoría Especial" en el Servicio de Urgencias de un hospital de tercer nivel.

OBJECTIVE: The aim of the study was to analyze the adequacy of the special category antibiotics prescriptions in the Emergency Department (ED) of a third level urban Hospital. METHODS: A random sample of 100 different patients who were started with a special category antibiotic along 2018 in the ED was selected. The research team reviewed the medical history of the emergency and admission episode. The independent factors associated with the degree of adequacy of the treatment were determined by logistic regression. RESULTS: A total of 97 prescriptions were analyzed of which 66 (68%) met the criteria of adequate prescription, 23 (24%) adequate prescription, but with equally recommended alternatives and 8 (8%) were inappropriate prescriptions. The degree of adequacy was 70% if the infection was related to healthcare and 75% if the patient had risk factors for mul-tiresistant (MR) microorganisms' infection. The percentage of adequacy was higher in the cases in which the focus of the infection (72%) and the severity of the episode (73%) were specified. The independent variables that were associated with an adequate prescription were: the presence of risk factors for MR microorganisms' infection (OR: 2.35 95% CI: 1.65 - 3.17 p: 0.01), if the focus of the infection (OR: 3.79 95% CI: 1.72 - 4.22 p: 0.02) and the severity of the episode (OR: 3.09 95% CI: 1.12 - 3.09 p: 0.03) were specified. CONCLUSIONS: The prescription of special category antibiotics in ED is appropriate if the clinical guidelines are followed and if the setting of infection acquisition, the risk factors of MR microorganisms, the focus and the severity of infection are taken into account in clinical picture.

Cytomegalovirus infection in HIV-infected patients in the era of combination antiretroviral therapy.

BACKGROUND: Cytomegalovirus infection dramatically decreased with the introduction of antiretroviral therapy. Whether incidence, clinical characteristics and prognosis of cytomegalovirus in HIV infected patients, has changed over time is. scarcely known. METHODS: Retrospective single-center study. Patients included in this study were all HIV infected patients that went to our center for any disease, and were diagnosed with cytomegalovirus, during the period 2004-2015. epidemiological, clinical and laboratory patients variables were collected in a clinical database. Clinical characteristics, incidence of cytomegalovirus and predictors of mortality during the study were assessed. Results were considered statistically significant when p < 0.05. All statistical analyses were calculated by SPSS version 20.0 (Chicago, IL,USA). RESULTS: Fifty-six cases of cytomegalovirus infection, in HIV infected patients were identified during the study period (incidence rate-1.7 cases per 1000 persons/year). The most frequent presentation was systemic illness in 43% of cases. Of note,no patients presented with ophthalmic manifestations. The 30-days mortality was 18%. Predictors of mortality were, in the univariate analysis, admission to the intensive care unit OR 32.4 (3.65-287.06) p = 0.0001, and mechanic ventilation 84 OR (8.27-853.12) p = 0.0001, and ART OR 4.1 (0.97-17.31) p = 0.044. These variables were assessed by multivariate analysis, and only mechanical ventilation was statistically significant (p < 0.05) CONCLUSION: Incidence of cytomegalovirus infection was higher than described in the antiretroviral therapy era. Clinical presentation has changed. Mechanic ventilation predicted mortality.

Full blood count values as a predictor of poor outcome of pneumonia among HIV-infected patients.

BACKGROUND: To evaluate the predictive value of analytical markers of full blood count that can be assessed in the emergency department for HIV infected patients, with community-acquired pneumonia (CAP). METHODS: Prospective 3-year study including all HIV-infected patients that went to our emergency department with respiratory clinical infection, more than 24-h earlier they were diagnosed with CAP and required admission. We assessed the different values of the first blood count performed on the patient as follows; total white blood cells (WBC), neutrophils, lymphocytes (LYM), basophils, eosinophils (EOS), red blood cells (RBC), hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin concentration, mean corpuscular hemoglobin, red blood cell distribution width (RDW), platelets (PLT), mean platelet volume, and platelet distribution width (PDW). The primary outcome measure was 30-day mortality and the secondary, admission to an intensive care unit (ICU). The predictive power of the variables was determined by statistical calculation. RESULTS: One hundred sixty HIV-infected patients with pneumonia were identified. The mean age was 42 (11) years, 99 (62%) were male, 79 (49%) had ART. The main route of HIV transmission was through parenteral administration of drugs. Streptococcus pneumonia was the most frequently identified etiologic agent of CAP The univariate analysis showed that the values of PLT (p < 0.009), EOS (p < 0.033), RDW (p < 0.033) and PDW (p < 0.09) were predictor of mortality, but after the logistic regression analysis, no variable was shown as an independent predictor of mortality. On the other hand, higher RDW (OR = 1.2, 95% CI 1.1-1.4, p = 0.013) and a lower number of LYM (OR 2.2, 95% CI 1.1-2.2; p = 0.035) were revealed as independent predictors of admission to ICU. CONCLUSION: Red blood cell distribution and lymphocytes were the most useful predictors of disease severity identifying HIV infected patients with CAP who required ICU admission.

Colonic content: effect of diet, meals, and defecation.

BACKGROUND: The metabolic activity of colonic microbiota is influenced by diet; however, the relationship between metabolism and colonic content is not known. Our aim was to determine the effect of meals, defecation, and diet on colonic content. METHODS: In 10 healthy subjects, two abdominal MRI scans were acquired during fasting, 1 week apart, and after 3 days on low- and high-residue diets, respectively. With each diet, daily fecal output and the number of daytime anal gas evacuations were measured. On the first study day, a second scan was acquired 4 hours after a test meal (n=6) or after 4 hours with nil ingestion (n=4). On the second study day, a scan was also acquired after a spontaneous bowel movement. RESULTS: On the low-residue diet, daily fecal volume averaged 145 ± 15 mL; subjects passed 10.6 ± 1.6 daytime anal gas evacuations and, by the third day, non-gaseous colonic content was 479 ± 36 mL. The high-residue diet increased the three parameters to 16.5 ± 2.9 anal gas evacuations, 223 ± 19 mL fecal output, and 616 ± 55 mL non-gaseous colonic content (P<.05 vs low-residue diet for all). On the low-residue diet, non-gaseous content in the right colon had increased by 41 ± 11 mL, 4 hours after the test meal, whereas no significant change was observed after 4-hour fast (-15 ± 8 mL; P=.006 vs fed). Defecation significantly reduced the non-gaseous content in distal colonic segments. CONCLUSION & INFERENCES: Colonic content exhibits physiologic variations with an approximate 1/3 daily turnover produced by meals and defecation, superimposed over diet-related day-to-day variations.

Colonic content in health and its relation to functional gut symptoms.

BACKGROUND: Gut content may be determinant in the generation of digestive symptoms, particularly in patients with impaired gut function and hypersensitivity. Since the relation of intraluminal gas to symptoms is only partial, we hypothesized that non-gaseous component may play a decisive role. METHODS: Abdominal computed tomography scans were evaluated in healthy subjects during fasting and after a meal (n = 15) and in patients with functional gut disorders during basal conditions (when they were feeling well) and during an episode of abdominal distension (n = 15). Colonic content and distribution were measured by an original analysis program. KEY RESULTS: In healthy subjects both gaseous (87 ± 24 mL) and non-gaseous colonic content (714 ± 34 mL) were uniformly distributed along the colon. In the early postprandial period gas volume increased (by 46 ± 23 mL), but non-gaseous content did not, although a partial caudad displacement from the descending to the pelvic colon was observed. No differences in colonic content were detected between patients and healthy subjects. Symptoms were associated with discrete increments in gas volume. However, no consistent differences in non-gaseous content were detected in patients between asymptomatic periods and during episodes of abdominal distension. CONCLUSIONS & INFERENCES: In patients with functional gut disorders, abdominal distension is not related to changes in non-gaseous colonic content. Hence, other factors, such as intestinal hypersensitivity and poor tolerance of small increases in luminal gas may be involved.

Intestinal gas content and distribution in health and in patients with functional gut symptoms.

BACKGROUND: The precise relation of intestinal gas to symptoms, particularly abdominal bloating and distension remains incompletely elucidated. Our aim was to define the normal values of intestinal gas volume and distribution and to identify abnormalities in relation to functional-type symptoms. METHODS: Abdominal computed tomography scans were evaluated in healthy subjects (n = 37) and in patients in three conditions: basal (when they were feeling well; n = 88), during an episode of abdominal distension (n = 82) and after a challenge diet (n = 24). Intestinal gas content and distribution were measured by an original analysis program. Identification of patients outside the normal range was performed by machine learning techniques (one-class classifier). Results are expressed as median (IQR) or mean ± SE, as appropriate. KEY RESULTS: In healthy subjects the gut contained 95 (71, 141) mL gas distributed along the entire lumen. No differences were detected between patients studied under asymptomatic basal conditions and healthy subjects. However, either during a spontaneous bloating episode or once challenged with a flatulogenic diet, luminal gas was found to be increased and/or abnormally distributed in about one-fourth of the patients. These patients detected outside the normal range by the classifier exhibited a significantly greater number of abnormal features than those within the normal range (3.7 ± 0.4 vs 0.4 ± 0.1; p < 0.001). CONCLUSIONS & INFERENCES: The analysis of a large cohort of subjects using original techniques provides unique and heretofore unavailable information on the volume and distribution of intestinal gas in normal conditions and in relation to functional gastrointestinal symptoms.

Algoritmo de la vía aérea difícil en pediatría / No disponible

No disponible

Extremos / Boundaries

No disponible

Management of tracheal agenesis.

Complete tracheal agenesis is a very rare congenital anomaly that is only compatible with life in some cases with associated tracheo-oesophageal or broncho-oesophageal fistula. In most cases, concomitant congenital anomalies of the heart, digestive tract or genitourinary tract are present. It should be suspected in any neonate with a history of hydramnios, absent crying, respiratory distress and difficulty in intubation. The possibility for surgical correction or palliation rests on the extent of atresia present. We present a case of complete tracheal agenesis without tracheo nor broncho-oesophageal fistula (type II by Floyd's classification) - the diagnosis of which was prenatally suspected - and discuss the important features of the airway management of this condition.

The resting and activation issue of hypofrontality: a single photon emission computed tomography study in neuroleptic-naive and neuroleptic-free schizophrenic female patients.

BACKGROUND: Functional neuroimaging findings of "hypofrontality" in schizophrenic patients is still controversial, due to the heterogeneity of methods and patient samples. This study tries to prevent some of these concerns by studying neuroleptic-naive (NN) and neuroleptic-free (NF) young female patients both in resting conditions and during a frontal cognitive activation task. METHODS: Regional cerebral blood flow (rCBF) was studied at rest and during the Wisconsin Card Sorting Test (WCST) in 25 young acute unmedicated schizophrenic female patients (14 NN and 11 NF) and 15 female controls, using single photon emission computed tomography. RESULTS: The schizophrenic and control groups did not differ in rCBF during the baseline condition, but the schizophrenic group failed to activate the frontal lobe during the WCST condition. In addition, the left anterior temporal rCBF at rest correlated with the Scale for the Assessment of Positive Symptoms total score. CONCLUSIONS: The results suggest that hypofrontality in young acute unmedicated schizophrenic patients is a result of an inability to activate frontal regions during cognition, rather than a baseline decrease in frontal activity. Furthermore, positive symptoms seem to be associated with left temporal cortex activity.

Haloperidol: therapeutic window in schizophrenia.

Twenty-two schizophrenic inpatients were treated for 3 weeks with three randomly fixed oral doses of haloperidol (10, 20, or 30 mg). Analysis of the results by a nonlinear regression model revealed a curvilinear relationship between haloperidol levels in plasma and clinical response, as assessed on the Brief Psychiatric Rating Scale (pseudo-R2 = 0.85, F = 17.7, p < 0.001, correlation between coefficients ranged from 0.99 to -0.52). This curve defines roughly three drug level ranges (low, < 5.5 ng/ml; optimal, 5.5 to 14.4 ng/ml; and high or toxic, > 14.4 ng/ml), which are significant for clinical practice. Patients with high levels improve to a lesser extent or even worsen in negative symptoms, showing a nonstatistically significant trend to present more extrapyramidal symptoms. Our data thus support the existence of a therapeutic window for haloperidol. Schizophrenic patients with acute exacerbation and drug levels in this range would have a greater probability of global clinical improvement.

Prefrontal dysfunction in young acute neuroleptic-naive schizophrenic patients: a resting and activation SPECT study.

Regional cerebral blood flow (rCBF) was measured with single photon emission computed tomography (SPECT) in six neuroleptic-naive, young, acute schizophrenic patients and six normal control subjects. We evaluated rCBF changes in prefrontal areas at rest and during a prefrontal activation task, the Wisconsin Card Sorting Test (WCST). Schizophrenic patients had significantly higher prefrontal blood flow than did control subjects during the resting conditions. During activation, the control group showed significant increases in prefrontal blood flow, whereas the schizophrenic group did not. These results suggest that at rest there is no evidence of hypofrontality, whereas hyperfrontality seems to be the most frequent pattern in our selected sample of young acute neuroleptic-naive schizophrenic patients. Furthermore, schizophrenic patients seem to be unable to increase prefrontal blood flow under conditions that challenge the prefrontal cortex.

Prefrontal and temporal blood flow in schizophrenia: resting and activation technetium-99m-HMPAO SPECT patterns in young neuroleptic-naive patients with acute disease.

UNLABELLED: This study assesses prefrontal and temporal regional cerebral blood flow (rCBF) changes in young, neuroleptic-naive schizophrenic patients with acute disease. METHODS: A selected population of 10 young, never-treated schizophrenic women with acute disease was studied by two hexamethylpropyleneamine oxime (HMPAO) brain SPECT sessions, performed 48 hr apart, both at rest and during a prefrontal activation task using the Wisconsin Card Sort Test (WCST). All patients met Diagnostic and Statistical Manual of Mental Disorders, 3rd edition-revised criteria for schizophrenia or schizophreniform disorder, were neuroleptic-naive and had acute symptoms. RESULTS: Under resting conditions, the schizophrenic group had significantly higher rCBF in the prefrontal regions, mainly in the left side and including the anterior cingulate, than did the controls. In addition, schizophrenic patients showed significant interhemispheric differences in prefrontal and posterior temporal index values at rest (left hyperfrontality and left hypotemporality). During WCST activation, the control group showed significant increases in prefrontal blood flow, whereas the schizophrenic group did not. CONCLUSION: These results support a physiologic dysfunction of the prefrontal cortex in schizophrenia that is present at the onset of the illness prior to neuroleptic treatment. Furthermore, both left hyperfrontality and left hypotemporality may indicate a brain lateralization defect in schizophrenia.

Positive versus negative symptoms in schizophrenia: response to haloperidol.

1. Clinical response to treatment with haloperidol was studied in 20 schizophrenic inpatients with acute exacerbation (DSM-IIIR). 2. Patients were assigned to fixed doses of haloperidol (10, 20 or 30 mg/day) for three weeks. Clinical assessment was made using scales SAPS, SANS, BPRS and Simpson-Angus Scale for rating of extrapyramidal side effects. 3. Sixteen patients showed forty per cent or more decrease in positive symptoms assessed by SAPS, being considered the group of responders. Six out of the twenty patients showed improvement in negative symptoms assessed by SANS (improvement above 30%). 4. Clinical predictors of response were only identified for SAPS. The group of responders showed higher basal scores in total scale and formal thought disorder. 5. Negative symptoms responsive to treatment were affective flattening and alogia. Improvement in negative symptoms was independent from that in positive ones. 6. Socio-demographic predictors of clinical response were not found. No differences in clinical response were found in relation to the dose administered. 7. The results of our study suggest that negative symptomatology improves in a scheduled treatment with haloperidol. Assessment of negative symptoms may be useful in the evaluation of treatment of acute schizophrenia.

[Evaluation of the quality of care of diabetic patients in 3 health centers]. / Evaluación de la calidad asistencial prestada a pacientes diabéticos en tres centros de salud.

The results of a retrospective health care quality assurance study are presented. This study was designed to evaluate the quality of health care rendered to diabetic patients who were diagnosed and/or treated in three medical centres. Nineteen criteria were chosen for the evaluation stage (385 diabetics, analysed) and 20 were used in the reevaluation (108 diabetics). The complementary test group met the most criteria, and the explorations group met the least, with the exception of blood pressure readings (77% of record). In the reevaluation stage, the percentage met of all the criteria under study increased, with statistically significant differences in all but three of the criteria. The standard of 100% was not attained in any of the cases, but the 85% mark was exceeded in 7 of the 20 criteria. A substantial improvement in the number of criteria recorded in the histories was observed, with an increase to 36.09% of histories with 17 or more criteria met, and a reduction, from 26.02% to 11.11%, of histories with 6 or less criteria met.