Influencia de los pesarios en la calidad de vida de las mujeres con prolapso de órganos pélvicos / No disponible

El prolapso de órganos pélvicos es una condición patológica que impacta negativamente en la calidad de vida de la mujer. Ocurre cuando los músculos, los ligamentos y las fascias del suelo pélvico se estiran y se debilitan, dejando de proporcionar un sostén adecuado, pudiendo descender y salir al exterior (1). La prevalencia está estimada de un 43% a un 76% de la población femenina general, siendo la etiología compleja y multifactorial (2). El pesario es un dispositivo que se instala en la vagina para proveer soporte a los órganos pélvicos. La importancia de su utilización reside en mejorar significativamente la calidad de vida de la paciente y evitar una intervención quirúrgica. El tratamiento es mínimamente invasivo, de bajo coste, seguro y efectivo. Se recomienda cuando la cirugía representa un riesgo mayor a los beneficios (3)

Pelvic organ prolapse is a pathological condition that negatively affects women's quality life. It occurs when the muscles ligaments and tissues supporting the pelvic organs become weak or loose. Then, the pelvic organs can droop down and bulge out of the vagina. The prevalence in women is estimated to be between 43 and 76%, etiology is complex and multifactorial. A pessary is a device inserted into the vagina to support areas that are affected by pelvic organ prolapse. The potential benefit that derives form pessary use is the significant improvement in the patient's quality of life. Thus, pessary treatment allows surgery to be avoided. It is minimally invasive, inexpensive, safe and effective treatment. It is therefore recommended when surgery may pose greater risk than benefit

Manual para la elaboración de documentos basados en la evidencia. Herramientas derivadas del conocimiento científico / Handbook for the preparation of evidence-based documents. Tools derived from scientific knowledge

Objetivo. El manual pretende ser una guía, accesible y fácil de consultar, que oriente a los profesionales en la elaboración o adaptación de documentos basados en la evidencia que ayuden a la estandarización de la práctica clínica y a la toma de decisiones velando siempre por la calidad de la misma de forma que siga unos referentes establecidos. Material y métodos. La Comisión de Atención Sanitaria Basada en la Evidencia (CASBE), perteneciente a la estructura de calidad del Hospital Universitario Virgen del Rocío, propuso elaborar un manual para la elaboración de documentos basados en la evidencia que incorpore la relación de productos, la descripción de sus características, atributos, utilidad, metodología de elaboración y ámbito de aplicación de cada uno de ellos. Resultados. El manual contiene 7 herramientas basadas en la evidencia, un capítulo sobre metodología de análisis crítico de la literatura científica, un capítulo con recursos en Internet y anexos con herramientas de evaluación. Conclusiones. Este manual ofrece grandes oportunidades para la mejora de la calidad a los clínicos como guía de estandarización de la práctica asistencial, a los gestores como estrategia para promover y fomentar la elaboración de documentos que ayuden a reducir la variabilidad de la práctica clínica y a los pacientes la oportunidad de participar en la planificación de sus cuidados(AU)

Objectives. This handbook is intended to be an accessible, easy-to-consult guide to help professionals produce or adapt Evidence-Based Documents. Such documents will help standardize both clinical practice and decision-making, the quality always being monitored in such a way that established references are complied with. Materials and methods. Evidence-Based Health Care Committee, a member of “Virgen del Rocío” University Hospital quality structure, proposed the preparation of a handbook to produce Evidence-Based Documents including: a description of products, characteristics, qualities, uses, methodology of production, and application scope of every one of them. Results. The handbook consists of seven Evidence-Based tools, one chapter on critical analysis methodology of scientific literature, one chapter with internet resources, and some appendices with different assessment tools. Conclusions. This Handbook provides general practitioners with a great opportunity to improve quality and as a guideline to standardize clinical healthcare, and managers with a strategy to promote and encourage the development of documents in an effort to reduce clinical practice variability, as well as giving patients the opportunity of taking part in planning their own care(AU)

[Handbook for the preparation of evidence-based documents. Tools derived from scientific knowledge]. / Manual para la elaboración de documentos basados en la evidencia. Herramientas derivadas del conocimiento científico.

OBJECTIVES: This handbook is intended to be an accessible, easy-to-consult guide to help professionals produce or adapt Evidence-Based Documents. Such documents will help standardize both clinical practice and decision-making, the quality always being monitored in such a way that established references are complied with. MATERIALS AND METHODS: Evidence-Based Health Care Committee, a member of "Virgen del Rocío" University Hospital quality structure, proposed the preparation of a handbook to produce Evidence-Based Documents including: a description of products, characteristics, qualities, uses, methodology of production, and application scope of every one of them. RESULTS: The handbook consists of seven Evidence-Based tools, one chapter on critical analysis methodology of scientific literature, one chapter with internet resources, and some appendices with different assessment tools. CONCLUSIONS: This Handbook provides general practitioners with a great opportunity to improve quality and as a guideline to standardize clinical healthcare, and managers with a strategy to promote and encourage the development of documents in an effort to reduce clinical practice variability, as well as giving patients the opportunity of taking part in planning their own care.

Cardiac allograft vasculopathy: coronary computed tomography and virtual histology assessment.

INTRODUCTION: Cardiac allograft vasculopathy remains the leading cause of late morbidity and mortality in heart transplantation. The main diagnostic methods, coronary angiography or intracoronary ultrasound (when angiography is normal), are invasive. Other study methods, such as coronary computed tomography (CT) and virtual histological analysis, have not been widely assessed in this condition. OBJECTIVE: The objective of this study was to assess the correlation between data obtained from analysis of virtual histology compared with those obtained from the performance of coronary CT in cardiac transplant recipients. MATERIALS AND METHODS: During the same admission we performed coronary angiography and intravascular ultrasound with virtual histological analysis (automatic pull-back in anterior descending artery and one additional vessel if the former was normal) as well as coronary CT. RESULTS: The study included 10 patients. Virtual histology was done in segments with intimal thickening>0.5 mm, defining 2 groups of plaque, those with an inflammatory component (necrotic core>30% and calcium) versus those without it defined as the combination of both being <30%. A calcium component of the inflammatory plaque allowed coronary CT detection. CONCLUSIONS: The detection of inflammatory plaque in graft vessel disease can be based on an initial noninvasive method, such as coronary CT, although confirmation requires further study.

Safety and effectiveness of ivabradine after cardiac transplantation.

BACKGROUND: Heart denervation is the primary cause of sinus tachycardia in transplant recipients. Drugs are usually needed to treat associated symptoms. OBJECTIVE: To evaluate the safety and effectiveness of the novel I(f) channel antagonist ivabradine to control heart rate after transplantation. METHODS: Of 316 heart transplant recipients at a single center since 1991, ivabradine was administered in 15 patients, in addition to ß-blockers in 4 patients and contraindication to use of ß-blocker therapy in the others. A prospective follow-up study was conducted to identify possible adverse effects, tolerance, and drug effects on heart rate and control of symptoms. RESULTS: Of the 15 patients, 13 were men; overall mean (SD) patient age was 46 (4.6) years. In all patients, treatment was begun after verification of basal heart rate greater than 100 bpm and after other causes of sinus tachycardia had been ruled out. During follow-up of 1.13 (0.3) years, no substantial adverse effects were observed. It was possible to reach the maximum drug dosage in all patients, achieving a reduction in basal heart rate of 33 (6.2) bpm. All patients reported substantial clinical improvement, and demonstrated an increase in functional class. CONCLUSION: Ivabradine is safe, well tolerated, and effective in heart transplant recipients.

Osteoporosis transitoria de cadera y gestación / Transient osteoporosis of the hip and pregnancy

La osteoporosis transitoria de cadera es una entidad rara, de etiología desconocida. Afecta a varones de mediana edad y a mujeres en el tercer trimestre del embarazo. Se caracteriza por dolor inguinal agudo, progresivo e incapacitante sin antecedente de traumatismo.Las pruebas de laboratorio son normales, a excepción de la velocidad de sedimentación globular y los valores urinarios de hidroxiprolina, que pueden estar elevados. Los hallazgos radiológicos consisten en una desmineralización de la cabeza femoral, pero se manifiestan después de un periodo de ventana de 4-6 semanas. La resonancia magnética es la prueba más sensible y específica para su diagnóstico temprano, lo cual es importante para evitar potenciales complicaciones como fracturas patológicas.La resolución suele ser espontánea a los 6-8 meses, tanto clínica como radiológica. El tratamiento consiste en analgesia y descarga del miembro afectado. La calcitonina se utiliza como analgésico y parece disminuir la duración del proceso. Los bifosfonatos pueden también mejorar el pronóstico del mismo modo.Se describe un caso de osteoporosis transitoria de cadera bilateral en una gestante (AU)

Transient osteoporosis of the hip (TOH) is a rare disorder of unknown etiology, characterized by acute, progressive disabling pain in the hip without prior trauma. This disease is more common among middle-aged men and during the third trimester of pregnancy.Laboratory values are normal, except for erythrocyte sedimentation rate and urinary hydroxyproline levels, which can be elevated. Radiologic findings consist of demineralization of the femoral head, but are only apparent after a window of 4-6 weeks. Magnetic resonance imaging has been proven to be the most accurate test for an early diagnosis, which can be important to avoid potential complications such as pathological fractures.Both clinical and radiological signs of TOH usually resolve spontaneously at 6-8 months. Treatment consists of analgesics and restricted weight bearing of the affected limb. Calcitonin may be used as an analgesic and to shorten disease duration. Bisphosphonates are another alternative. We report a case of severe bilateral TOH in a pregnant woman (AU)

Usefulness of cardio MRI on thrombosis of coronary aneurysm as an infrequent cause of ST-elevation coronary syndrome.

We present an unusual case of thrombosis of coronary aneurysm causing myocardial infarction with ST-elevation in precordial leads. Emergent coronary angiography showed thrombotic occlusion of an aneurysm in the proximal segment of the left anterior descendent coronary artery (LAD). After the administration of tenecteplase, pain and ST-elevation disappeared with no overt complications. Cardiac magnetic resonance imaging (MRI) performed two weeks after admission showed thrombi partially filling the aneurysm together with further information regarding coronary anatomy, as well as a preserved global function even though delayed enhancement of the myocardium was patent throughout the territory irrigated by LAD. This case supports cardio MR usefulness in Kawasaki disease in order not only to depict coronary abnormalities, but also to provide accurate information regarding function and viability in a non-invasive way. It also highlighted the relevance of a proper selection of the sequence technique when thrombus is suspected. All these advantages point out to cardiac MRI as the modality of choice in the follow-up of patients in this clinical scenario.

Gestión de la seguridad del paciente en una unidad de urgencias de atención primaria / Ensuring patient safety in an emergency primary health care service

Objetivo: La seguridad clínica o los riesgos a los que se someten los pacientes en función de su relación con el sistema sanitario han sido mencionados con mucha frecuencia en el desarrollo de las ciencias sanitarias. Ciertas unidades, como las de pacientes críticos, son más propicias a errores por la multitud de fármacos y procedimientos. El objetivo del estudio fue describir la experiencia en el análisis de los efectos adversos(EA) en urgencias de atención primaria y, aún más, propiciar la identificación y prevención de los EA antes de que estos ocurran. Método: Creación de un grupo de trabajo en noviembre de 2007 en la unidad clínica de urgencias del centro de salud para definir las situaciones de riesgo donde se pueden producir EA, prevenir su aparición, analizar los que aparezcan y corregirlos dentro de un contexto de mejora continua de calidad asistencial. Realizamos un análisis y estudio descriptivo retrospectivo sobre las notificaciones de EA durante el año 2008.Resultados: Se atendieron un total de 75.525 urgencias, y en total se detectaron 11EA (0,15‰), de los que 9 corresponden a errores de identificación en la apertura del episodio clínico (errores de filiación) y dos a EA con consecuencias clínicas leves. Conclusiones: El EA más frecuente es el error de identificación en la apertura del episodio clínico o historia clínica, lo que conlleva (de no corregirse a tiempo) a la generación de un episodio de asistencia urgente a una persona que no le corresponde (AU)

Objective: Clinical safety and the risks affecting patients in their relations with the health care system have long been discussed in the health sciences. Certain settings, such as critical care units, are highly susceptible to error because of the many drugs and procedures they manage. Our main objetive was to initiate analysis of adverse events in an emergency primary health care service, as well as to facilitate the identification and prevention of such events. Methods: A working group was formed in November 2007 in our emergency primary health care service and charged with defining situations in which there is risk of adverse events, preventing such events, and analyzing and correcting those that occurred with a view to making ongoing improvements in patient care. We undertook a retrospective study of adverse event reports in 2008.Results: We attended 75525 consultations, and found 11 incidents (0,15‰). Nine were caused by errors in identifying the onset of the episode (referral errors) and 2 were events with scarce clinical consequences. Conclusions: Mistakes in identifying the onset of a clinical episode or relevant medical history are the most common type of event. This error generates the need for an emergency department visit that could have been avoided if the error had been corrected in time (AU)

Taquicardia de QRS ancho en mujer joven con síndrome coronario agudo secundario a disección coronaria espontánea / Wide QRS tachycardia in a young woman with acute coronary syndrome secondary to spontaneous coronary dissection

No disponible

Epidermólisis ampollosa distrófica recesiva y gestación / Recessive dystrophic epidermolysis bullosa and pregnancy

La epidermólisis ampollosa distrófica recesiva noHallopeau-Siemens (EADR no-HS) es unaenfermedad hereditaria de la piel, infrecuente,caracterizada por una falta de adhesión cutánea quepuede involucrar también a mucosas, cuyo cursono se ve afectado por la gestación. Se debe ofrecerconsejo genético a las parejas que hayan tenido unniño con esta afección, ya que un 25% de los hijosde dichas parejas pueden tener la enfermedad. Sinembargo, en el caso de las pacientes, al tratarse deuna forma recesiva, el riesgo de tener un niñoafectado es menor de un 1%, recomendándose enestos casos el diagnóstico prenatal únicamente siexisten antecedentes familiares en su pareja oconsanguinidad o sospecha de consanguinidad(p. ej., ambas familias oriundas de una mismaregión geográfica). El parto por vía vaginal y lalactancia no están contraindicados, pero son difícilesy requieren una valoración individualizada y unoscuidados especiales (AU)

Recessive non-Hallopeau-Siemens dystrophicepidermolysis bullosa is a rare and severe inheritedskin disease characterized by increased skinfragility that can also involve the mucosa. Thisentity is not associated with pregnancycomplications. Genetic counselling must be offered,because the risk of recurrence in parents with anaffected child is 25%. However, becausetransmission is recessive, the risk of having affectedoffspring in individuals with the disease is lessthan 1%. Therefore prenatal diagnosis is onlyrequired if the partner has a familial history of thedisease or if there is consanguinity or suspectedconsanguinity (for example, if both families arefrom the same geographical area). Vaginal deliveryand breast feeding are not contraindicated, but aredifficult and require individual assessment andclose monitoring (AU)

[Circumscribed choroidal hemangioma treated with photodynamic therapy]. / Hemangioma circunscrito de coroides tratado con terapia fotodinámica.

CLINICAL CASE: A 45-year-old male referred with a scotoma in the left eye of 2 months' evolution. A peripapillary tumor was found, with a basal diameter of 7 mm and thickness 3.4 mm. It was diagnosed as a circumscribed choroidal hemangioma. It was decided to treat the patient using photodynamic therapy. After 4 sessions and 17 months follow-up, the patient remained asymptomatic and visual acuity was stable. There was evidence of subretinal fibrosis and no subretinal fluid was found. DISCUSSION: Photodynamic therapy is a good option for the treatment of circumscribed choroidal hemangioma given the minimal damage is causes to the adjacent retina.

Clinical randomized controlled trial of chemomechanical caries removal (Carisolv).

OBJECTIVES: The purpose of this study was to compare the chemomechanical caries-removal system (Carisolv) with high-speed excavation in cavitated occlusal caries of primary molars. Design and setting. The study was a randomized controlled, clinical trial in which the two techniques were compared in each subject. Participants were chosen from public schools, in Maracaibo County, Zulia State, Venezuela. SAMPLE AND METHODS: The sample consisted of 80 primary molars selected from 40 children (mean age 7.7+/-0.7 years). Each patient had at least two contralateral primary molars with cavitated occlusal caries and approximately equal-size access to lesions. The outcome variables were: clinically complete caries removal, size of the opening of the cavity, volume of carious tissue removed, pain during caries removal, anaesthesia requested by the patient, caries-removal time, and behaviour and preference of patients. RESULTS: All treated molars were clinically caries free whichever caries-removal procedure was used. When Carisolv' was used the final cavity entrance sizes were smaller (P<0.001) and the estimated volume of tissue removed was less (P<0.001). The time taken for caries removal was three times longer (7.51+/-1.83 min, P<0.001). Some pain was reported by seven (17.5%) participants when Carisolv was used, compared with 16 (40%) when high-speed excavation was used (P<0.05). Using the Carisolv method there was a higher proportion of patients with positive behaviour (P<0.01), and 71.0% (P<0.05) preferred this treatment. CONCLUSION: Carisolv is an effective clinical alternative treatment for the removal of occlusal dentinal caries in cavitated primary molars; it is more conservative of dental tissue and appeared to be more comfortable for most patients, although the clinical time spent is longer than when using high-speed excavation.

Hematoma en psoas / Psoas hematoma

No disponible

Population pharmacokinetics of digoxin in pediatric patients.

Digoxin pharmacokinetics were studied in a pediatric population with an age range of 6 days to 1 year using the population pharmacokinetic approach. Digoxin data were analyzed by mixed-effects modeling according to a one-compartment steady-state pharmacokinetic model using NONMEM software. The final model selected for the population prediction of digoxin clearance in pediatric patients was as follows: [equation: see text] Individual empirical Bayesian estimates were generated on the basis of the population estimates and were used to correlate the optimum dose of digoxin and patient age according to the following equation: [equation: see text] This equation and its derived nomogram may be used for the initial dosing of digoxin in children aged between 0 and 1 year. The use of this nomogram in routine monitoring requires further pharmacokinetic and clinical validation.

[Contribution of color Doppler in the diagnosis of bilateral ductus arteriosus]. / Contribución del Doppler color al diagnóstico de ductus arterioso bilateral.

We report a neonate with distal bilateral ductus arteriosus origin of nonconfluent pulmonary arteries which was only diagnosed accurately by 2-D echo Doppler color flow mapping in the context of situs ambiguous, univentricular A-V connection and pulmonary atresia with normal systemic/pulmonary venous drainage. The color flow appearance of this singular vascular anatomy was enhanced after prostaglandin administration, which, allowed us to see an image resembling a "moustache morphology". At 36 months of age, and after a successful bilateral 4 mm modified Blalock Taussig shunt implantation by sequential approach, the patient is waiting for the next surgical step which will include a restoration of the confluence of the pulmonary arteries with bidirectional Glenn operation. Brief embryological and differential diagnosis comments are discussed.

[Clinical and echocardiographic impact of neonatal aortic valvuloplasty]. / Impacto clínico y ecocardiográfico de la valvuloplastia aórtica neonatal.

OBJECTIVES: The selection of patients for balloon aortic valvuloplasty is a vital clinical challenge in neonatal aortic stenosis. The present study was designed to establish possible predicting factors for poor results after balloon therapy. PATIENTS AND METHODS: 2D echocardiographic, Doppler color and clinical variables (grade of cardiac failure, aortic "anulus", mitral anulus, left ventricular diameter, ascending aorta, instantaneous Doppler gradient, and grade of aortic regurgitation) were analyzed in 32 neonates submitted to balloon dilation at 22 +/- 18 days of life. The evaluations were conducted during three periods in respect to balloon therapy (A: before; B: immediately after, and C: mid-term follow-up). The outcome in both, B and C periods was defined as favorable (all survivors with Doppler gradient < or = 70 mmHg and no other intervention on the valve) and unfavorable (death, first stage of univentricularization, valvular replacement or survivors with Doppler gradient > 70 mmHg). Mean values between subgroups were compared by Wilcoxon test; unconditional logistic regression was used to analyze the impact of cardiac failure and anatomic variables (continuous, categorized or Z) on the outcome. RESULTS: The Doppler gradient decreased from 70 +/- 28 to 34 +/- 14 mmHg after the valvuloplasty, and no changes were detected in the follow-up period (36 +/- 8 mmHg). An immediate favorable result was obtained in 72% of the patients; its consisted of 50% in period C. Nine neonates had an immediate unfavorable outcome (6 deaths and 3 with Norwood operation). In the follow-up, three patients had valvular replacement, one patient Doppler gradient > 70 mmHg and one patient with left ventricular endomyocardial abnormalities died. The severe cardiac failure (odds ratio: 33; CL 2.4-443; p = 0.008) and all categorized anatomic variables (aortic "anulus" < or = 6 mm; mitral anulus < or = 9 mm; ascending aorta < or = 8 mm; left ventricular diameter < or = 13 mm) were related with the immediate poor outcome. At 7.6 years, survival and freedom with no valvular replacement nor reintervention probability rates were 83% and 67%, respectively. CONCLUSIONS: 2D echo Doppler provides essential information about the anatomic and functional lesions coexisting with severe or critical aortic stenosis in neonates. Patients with left heart hypoplasia and severe heart failure should not be candidates for balloon valvuloplasty. The degree of residual aortic regurgitation and endomyocardial abnormalities of the left ventricle play an important role in the mid-term follow-up.