Contribución de la inteligencia sanitaria a la formación / Contribution of medical intelligence to training

La inteligencia sanitaria contribuye de forma importante a la mejora de la práctica clínica y la formación del personal militar de sanidad como es a través del análisis de la información sanitaria y aplicación de los resultados de este análisis a la mejora de la atención del paciente traumático grave. Los registros de trauma recogen datos que son de utilidad para su posterior análisis colaborando en el desarrollo, mejora, actualización e implantación de programas de enseñanza para el personal de sanidad en los que tiene un papel fundamental la simulación clínica. Material y métodos:Se ha realizado una búsqueda no sistemática en distintas bases de datos como Medline, Revista Military Medicine o Google Académico.Resultados y discusión:En Europa existen distintos registros de trauma, tanto civiles como militares, que recogen datos de distintos aspectos de la atención al paciente politraumatizado.Conclusión:El análisis por parte de la inteligencia sanitaria de los datos registrados y una formación eficaz con la inclusión de simulación clínica, contribuirá a la mejora de la formación del personal sanitario, tanto civil como militar, y por lo tanto al aumento de la supervivencia del paciente con trauma grave. (AU)

Introduction: Medical Intelligence contributes significantly to the improvement of clinical practice and training of military health personnel, such as through health information analysis and application of the results of this analysis to the improvement of patient severe trauma care. Trauma registries collect data that are useful for further analysis by collaborating in the development, improvement, updating and implementation of education programmes for health personnel where clinical simulation plays a key role.Material and methods:An unsystematic review has been carried out on different databases such as Medline, Military Medicine Magazine or Google Scholar.Results and discussion:In Europe there are different trauma registries, both civilian and military, which collect data on different aspects of the care of the trauma patient.Conclusion:Analysis by the Medical Intelligence of the registered data and effective training, including clinical simulation, will contribute to the improvement of the training of health personnel, both civilian and military, and therefore to increase the patient survival with severe trauma. (AU)

Efecto de la variabilidad glucémica intrahospitalaria en la mortalidad de los pacientes con diabetes / Effect of in-hospital glycemic variability on mortality in patients with diabetes

Introducción El objectivo fue evaluar la importancia de glucemia media (GM) y variabilidad glucémica (VG) durante la hospitalización sobre la mortalidad tras el alta.Material y métodosEstudio de cohortes retrospectivo longitudinal analítico. Se incluyeron pacientes dados de alta del Servicio de Medicina Interna con algún diagnóstico relacionado con la diabetes. El pronóstico evaluado fue la mortalidad. Se recogieron durante el ingreso variables clínicas, analíticas y relacionadas con el control glucémico hospitalario (GM, VG e hipoglucemias). La VG se midió con el coeficiente de variación (CV).Se calcularon las tasas de mortalidad por cada 1000 pacientes-año y se compararon con curvas de Kaplan-Meier. La determinación de los factores predictivos de mortalidad se realizó mediante regresión de Cox.ResultadosSe incluyeron 276 pacientes con edad media 77,6 (DE 10,2) años. La duración mediana del seguimiento extrahospitalario fue de 2,7 años.En análisis multivariante, una GM > 140 (HR=1,72; IC 95% 1,14-2,61; p=0,01) y un CV > 0,29 (HR=1,52; IC 95% 1,12-2,06; p=0,006), no así la presencia de hipoglucemias, se asociaron a incremento del riesgo de mortalidad de forma aditiva e independiente. Tener una GM > 140 simultáneamente con un CV > 0,29 incrementó las tasas de mortalidad (123 vs. 317 por 1.000 pacientes-año; p <0,001) y el riesgo ajustado de mortalidad (HR=2,70; IC 95% 1,71-4,27; p<0,001) respecto a tener una GM ≤ 140mg/dl.ConclusiónLa presencia simultánea de GM y VG elevadas constituye una potente herramienta de estratificación del riesgo de mortalidad tras el alta hospitalaria. (AU)

Introduction The aim of this study was to evaluate the impact of mean blood glucose (MBG) and glycaemic variability (GV) during hospitalisation on mortality after discharge.Material and methodsWe conducted a retrospective longitudinal analytical cohort study that included patients discharged form a department of internal medicine with a diabetes-related diagnosis The evaluated prognosis was mortality. During hospitalisation, the patients’ clinical, laboratory and glycaemic control-related variables were recorded (MBG, GV and hypoglycaemia). The GV was measured with the coefficient of variation (CV).We calculated the mortality rates for every 1000 patient-years and compared them with Kaplan-Meier curves. We determined the predictors of mortality by performing a Cox regression.ResultsThe study included 276 patients with a mean age of 77.6 (SD, 10.2) years. The median outpatient follow-up duration was 2.7 years.In the multivariate analysis, an MBG >140mg/dl (HR, 1.72; 95% CI 1.14–2.61; p=.01) and a CV >0.29 (HR, 1.52; 95% CI 1.12–2.06; p=.006) but not the presence of hypoglycaemia were additively and independently associated with an increased risk of mortality. An MBG >140mg/dl with a CV >0.29 increased the mortality rates (123 vs. 317 per 1000 patient-year; p <.001) and the adjusted mortality risk (HR, 2.70; 95% CI 1.71–4.27; p<.001) compared with having an MBG ≤140mg/dl.ConclusionThe simultaneous presence of a high MBG level and CV constitutes a powerful tool for stratifying mortality risk after hospital discharge. (AU)

Effect of in-hospital glycemic variability on mortality in patients with diabetes.

INTRODUCTION: The aim of this study was to evaluate the impact of mean blood glucose (MBG) and glycaemic variability (GV) during hospitalisation on mortality after discharge. MATERIAL AND METHODS: We conducted a retrospective longitudinal analytical cohort study that included patients discharged form a department of internal medicine with a diabetes-related diagnosis. The evaluated prognosis was mortality. During hospitalisation, the patients' clinical, laboratory and glycaemic control-related variables were recorded (MBG, GV and hypoglycaemia). The GV was measured with the coefficient of variation (CV). We calculated the mortality rates for every 1000 patient-years and compared them with Kaplan-Meier curves. We determined the predictors of mortality by performing a Cox regression. RESULTS: The study included 276 patients with a mean age of 77.6 (SD, 10.2) years. The median outpatient follow-up duration was 2.7 years. In the multivariate analysis, an MBG > 140 mg/dL (HR = 1.72; 95% CI 1.14-2.61; p = .01) and a CV > 0.29 (HR = 1.52; 95% CI 1.12-2.06; p = .006), but not the presence of hypoglycaemia, were additively and independently associated with an increased risk of mortality. An MG > 140 mg/dL with a CV > 0.29 increased the mortality rates (123 vs. 317 per 1000 patient-year; p < .001) and the adjusted mortality risk (HR = 2.70; 95% CI 1.71-4.27; p < .001) compared with having an MBG ≤ 140 mg/dL. CONCLUSION: The simultaneous presence of a high MBG level and CV constitutes a powerful tool for stratifying mortality risk after hospital discharge.

Síncope en la edad pediátrica / Syncope in the pediatric age

Introducción. El síncope es la pérdida brusca y transitoria del nivel de conciencia y del tono postural a consecuencia de una hipoperfusión cerebral transitoria. Desarrollo. Se trata de un síntoma muy frecuente en la edad pediátrica, sobre todo en la adolescencia y que, en ocasiones, genera gran angustia entre las familias e inseguridad entre los profesionales, abusándose de exploraciones y tratamientos innecesarios. En esta revisión daremos las claves para hacer un correcto diagnóstico diferencial, analizaremos los datos de alarma que nos deben hacer sospechar que no nos encontramos ante un cuadro benigno, veremos qué recomendaciones debemos dar a las familias y a los pacientes y cuándo remitir al especialista. Nuestros objetivos con esta revisión: saber enfocar correctamente el síncope en la edad pediátrica; tranquilizar cuando se trate de un proceso benigno e identificar los casos de potencial gravedad. Conclusiones. En la edad pediátrica los síncopes son en su mayoría benignos. El síncope reflejo, concretamente el vasovagal, es el más frecuente. La historia clínica es la clave para el diagnóstico. Debemos estar especialmente atentos a los datos de alarma en la historia y en el electrocardiograma que nos puedan indicar la presencia de una cardiopatía subyacente. Los niños con una historia compatible con síncope vasovagal, sin antecedentes familiares de riesgo y con electrocardiograma normal no precisan valoración cardiológica adicional. Entre los aspectos más importantes del tratamiento del síncope reflejo están formar y tranquilizar al niño y a la familia (AU)

Introduction. Syncope is the sudden and transient loss of the level of consciousness and postural tone due to a transient cerebral hypoperfusion. Development. This is a very frequent symptom in the pediatric age, above all in adolescent age and which, at times, generates great anxiety among the family and insecurity among the professionals, unnecessary examinations and treatments being abuse of. In this review, we present the keys to making a correct differential diagnosis. We analyze the alert data that should lead us to suspect that we are not facing a benign picture. We will see what recommendations we should give the family and patients and when to send them to the specialist. Our objectives with this review are: to know how to correctly approach the syncope in the pediatric age; to reassure when it is a benign process and to identify the cases having potential severity. Conclusions. Syncopes are mostly benign in the pediatric age. The reflex syncope, specifically the vasovagal one, is the most frequent. The clinical history is key for the diagnosis. We should be especially alert to the alarm data in the history and in the electrocardiogram that can indicate the presence of an underlying heart disease. Children with a history consistent with vasovagal syncope, with no family background of risk and with a normal electrocardiogram do not require additional cardiological evaluation. Among the most important aspects of treatment of the reflex syncope are those of informing and assuring the child and the family (AU)

Correction to: Merkel Cell Carcinoma Outcomes: Does AJCC8 Underestimate Survival?

C.R. Farley and M.C. Perez contributed equally to this publication and are co-first authors. J.S. Zager and M.C. Lowe contributed equally to this publication and are co-corresponding authors.

Effect of in-hospital glycemic variability on mortality in patients with diabetes. / Efecto de la variabilidad glucémica intrahospitalaria en la mortalidad de los pacientes con diabetes.

INTRODUCTION: The aim of this study was to evaluate the impact of mean blood glucose (MBG) and glycaemic variability (GV) during hospitalisation on mortality after discharge. MATERIAL AND METHODS: We conducted a retrospective longitudinal analytical cohort study that included patients discharged form a department of internal medicine with a diabetes-related diagnosis The evaluated prognosis was mortality. During hospitalisation, the patients' clinical, laboratory and glycaemic control-related variables were recorded (MBG, GV and hypoglycaemia). The GV was measured with the coefficient of variation (CV). We calculated the mortality rates for every 1000 patient-years and compared them with Kaplan-Meier curves. We determined the predictors of mortality by performing a Cox regression. RESULTS: The study included 276 patients with a mean age of 77.6 (SD, 10.2) years. The median outpatient follow-up duration was 2.7 years. In the multivariate analysis, an MBG >140mg/dl (HR, 1.72; 95% CI 1.14-2.61; p=.01) and a CV >0.29 (HR, 1.52; 95% CI 1.12-2.06; p=.006) but not the presence of hypoglycaemia were additively and independently associated with an increased risk of mortality. An MBG >140mg/dl with a CV >0.29 increased the mortality rates (123 vs. 317 per 1000 patient-year; p <.001) and the adjusted mortality risk (HR, 2.70; 95% CI 1.71-4.27; p<.001) compared with having an MBG ≤140mg/dl. CONCLUSION: The simultaneous presence of a high MBG level and CV constitutes a powerful tool for stratifying mortality risk after hospital discharge.

Low-energy short-term cold atmospheric plasma: Controlling the inactivation efficacy of bacterial spores in powders.

The present research work aims to elucidate kinetics and mechanisms of the inactivation of Bacillus subtilis spores by a surface micro-discharge (SMD) - cold atmospheric pressure plasma (CAPP). Regarding industrial applications, the inactivation of spores was also studied for a static layer of a biopolymer powder or film, with an air plasma and at ambient pressure. Close to 4 log10 cycles of inactivation of Bacillus subtilis spores were achieved when exposing spores on flat glass to the SMD-CAPP. This effect can be reached at a very low plasma power density of 5 mW/cm2 in 7 min exposure time. The maximum inactivation level of spores drops when treating corn-starch powder to 2.6 log10 cycles at 7 mW/cm2 plasma power density for 5 min and with a polymer load of 5 mg/cm2. Similar is true for films produced with hydroxymethyl cellulose (HMC). The inactivation efficacy can be tuned and is a function of applied surface energy (product of the plasma power density and the exposure time) and the polymer load. Plasma diagnostics reveal the fundamental importance of reactive nitrogen species (RNS) in the inactivation. Etching of spore hull is supposed to be triggered by the plasma density, while UV-C and UV-B radiation do not contribute directly and significantly to the inactivation effect at least in a biopolymer matrix. Fluidization of a fixed powder layer is supposed to overcome limitations of the inactivation efficacy by reducing the diffusion distance of active plasma species between the source and the sample. The combination of low plasma power density with short treatment time is supposed to reduce the risk of the formation of side-products from the matrix.

Merkel Cell Carcinoma Outcomes: Does AJCC8 Underestimate Survival?

INTRODUCTION: The eighth edition of the American Joint Committee on Cancer (AJCC8) Staging Manual provides important information for staging and prognostication; however, survival estimates for patients with Stage I-III Merkel cell carcinoma (MCC), a rare disease, may be as practical using data from large-volume centers as that collated for the AJCC analysis. As such, we compared our institutional outcomes to AJCC8. METHODS: Patients who presented from 2005 to 2017 with MCC to two high-volume centers were included. Demographics, clinicopathologic characteristics, survival and recurrence data were compiled, and outcomes compared to AJCC8. RESULTS: A total of 409 patients were included. Median age was 75 (range 29-98) years, and 68% were male. Median follow-up was 16 months (0-157). Five-year overall survival (OS) was 70%; 5-year disease-specific survival (DSS) was 84%. When stratified by extent of disease, 5-year OS was higher for patients with local disease compared to those with nodal disease (72.6% vs 62.7%, p=0.005). Similarly, patients with local disease had higher 5-year DSS than those with nodal disease (90.1% vs 76.8%, p=0.002). Five-year recurrence-free survival was 59.2% for all patients, 65.0% for local disease and 48.3% for nodal disease (p=0.033). CONCLUSIONS: Here, MCC patients with local or nodal disease have substantially higher OS rates than predicted in AJCC8 (5-year: 72.6% vs 50.6%; 62.7% vs 35.4%, respectively). Importantly, 5-year DSS was significantly better than the OS rates reported presently and in AJCC8. As clinicians and patients rely on AJCC to accurately prognosticate and guide treatment decisions, these estimates should be reassessed and updated to more accurately predict survival outcomes.

Real-world short-term effectiveness of ustekinumab in 305 patients with Crohn's disease: results from the ENEIDA registry.

BACKGROUND: There are limited data of ustekinumab administered according to the doses recommended in the UNITI studies. AIM: To assess the real-world, short-term effectiveness of ustekinumab in refractory Crohn's disease (CD) METHODS: Multicentre study of CD patients starting ustekinumab after June 2017 at the recommend dose (260, 390 or 520 mg based on weight ~6 mg/kg IV week 0 and 90 mg subcutaneously week 8). Values for Harvey-Bradshaw Index (HBI), C-reactive protein (CRP) and faecal calprotectin (FC) were recorded at baseline and at weeks 8 and 14. Demographic and clinical data, previous treatments, AEs and hospitalisations were documented. Possible predictors of clinical remission were examined. RESULTS: Three hundred and five patients were analysed (≥2 previous anti-TNFα therapies 64% and vedolizumab 29%). At baseline, 217 (72%) had an HBI >4 points. Of these, 101 (47%) and 126 (58%) achieved clinical remission at weeks 8 and 14, respectively. FC levels returned to normal (<250 µg/g) in 46% and 54% of the patients at weeks 8 and 14 respectively. CRP returned to normal (<3 mg/L) in the 35% and 41% of the patients at week 8 and 14 respectively. AEs were recorded in 38, and 40 patients were hospitalised. Intolerance to the most recent anti-TNF agent and fewer previous anti-TNF agents were associated with clinical remission at week 14. Endoscopic severity was associated with poor response. CONCLUSION: This is the first study to show the real-world effectiveness and safety of ustekinumab administered according to the recommended induction regimen in a cohort of highly refractory CD patients.

[Application of the Smoking Scale for Primary Care (ETAP) in clinical practice]. / Aplicación de la Escala de Tabaquismo para Atención Primaria (ETAP) en la práctica clínica.

OBJECTIVE: To determine if the ETAP smoking scale, which measures accumulated exposure to tobacco, both actively and passively, is applicable and effective in the clinical practice of Primary Care for the prevention of acute myocardial infarction (AMI). Location Barranco Grande Health Centre in Tenerife, Spain. DESIGN: A study of 61 cases (AMI) and 144 controls. Sampling with random start, without matching. COR-II curves were analysed, and effectiveness was estimated using sensitivity and negative predictive value (NPV). A questionnaire was provided to participating family physicians on the applicability of ETAP in the clinic. RESULTS: The opinion of the participating physicians was unanimously favourable. ETAP was easy to use in the clinic, required less than 3min per patient, and was useful to reinforce the preventive intervention. The ETAP COR-II curve showed that 20years of exposure was the best cut-off point, with an area under the curve of 0.70 (95%CI: 0.62-0.78), and a combination of sensitivity (98%) and NPV (96%) for AMI. When stratifying age and gender, all groups achieved sensitivities and NPVs close to 100%, except for men aged ≥55years, in whom the NPV fell to 75%. CONCLUSIONS: The results indicate that ETAP is a valid tool that can be applied and be effective in the clinical practice of Primary Care for the prevention of AMI related to smoking exposure.

Embryological and comparative description of the cephalic vein joining the external jugular vein: A case report.

The cephalic vein arises from the radial end of the dorsal venous arch. It turns around the radial border of the forearm and passes proximally along the arm to the shoulder, where it enters the axillary vein by penetrating the clavipectoral triangle. The cephalic vein is prone to vary at the antecubital fossa, where it forms numerous anastomoses. A male cadaver fixated with a 10% formalin solution was dissected during regular anatomy lessons. It was found that the cephalic vein crossed the upper third of the arm between two fasciculi of the deltoid muscle and reached the shoulder, where it passed above the acromion and crossed the posterior border of the clavicle in order to join the external jugular vein. The cephalic vein is one of the most used veins for innumerous activities, such as venipunctures and arteriovenous fistula creation. Furthermore, it is an anatomical landmark known for its consistent anatomy, as it possesses low rates of variability. Despite that, its anatomical variations are clinically and surgically significant and healthcare professionals must be aware of the variations of this vessel. We aim to report a rarely described variation of the cephalic vein and discuss its embryological, phylogenetic and clinical features.

Antimicrobial potential of macro and microalgae against pathogenic and spoilage microorganisms in food.

Algae are a valuable and never-failing source of bioactive compounds. The increasing efforts to use ingredients that are as natural as possible in the formulation of innovative products has given rise to the introduction of macro and microalgae in food industry. To date, scarce information has been published about algae ingredients as antimicrobials in food. The antimicrobial potential of algae is highly dependent on: (i) type, brown algae being the most effective against foodborne bacteria; (ii) the solvent used in the extraction of bioactive compounds, ethanolic and methanolic extracts being highly effective against Gram-positive and Gram-negative bacteria; and (iii) the concentration of the extract. The present paper reviews the main antimicrobial potential of algal species and their bioactive compounds in reference and real food matrices. The validation of the algae antimicrobial potential in real food matrices is still a research niche, being meat and bakery products the most studied substrates.

Stevia rebaudiana Bertoni effect on the hemolytic potential of Listeria monocytogenes.

The effect of Stevia rebaudiana Bertoni on the hemolytic potential of Listeria monocytogenes was studied by means of the assessment of the Listeriolysin O (LLO) production. The three factors under study, stevia concentration in the range [0-2.5] % (w/v), incubation temperature (10 and 37°C), and exposure time (0-65h) significantly affected (p≤0.05) the hemolytic activity of L. monocytogenes. Results showed that at the lower incubation temperature the hemolytic potential of the bacterium was significantly reduced, from 100% at 37°C to 8% at 10°C (after 65h of incubation) in unsupplemented substrate (0% stevia). Irrespective of the temperature, 10 or 37°C, supplementation of the medium with stevia at 2.5 % (w/v) reduced the bacterium's hemolytic activity by a maximum of 100%. Furthermore, the time of exposure to 2.5 % (w/v) stevia concentration was also a significant factor reducing the hemolytic capability of L. monocytogenes. The possibility of reducing the pathogenic potential of L. monocytogenes (hemolysis) by exposure to stevia should be confirmed in real food matrices, opening a research niche with a valuable future impact on food safety.

Programa integral para el cáncer en Cuba: Pautas para la gestión de implementación / Comprehensive program for cancer in Cuba: Guidelines for implementation management

Esta nueva edición sirve de orientación en la planificación y aplicación de intervenciones dirigidas a integrar el control del cáncer a las acciones del sistema nacional de salud, basa su actualización en el programa del médico y enfermera de la familia, y se estructura en paquetes tecnológicos como innovación para incorporar entre otros, los productos de la biotecnología. En ese sentido, organiza la gestión direccionada por el conocimiento, la socialización de las nuevas formas de organización establecidas para el control de la enfermedad.