Percepción del riesgo de infecciones de transmisión sexual/VIH en jóvenes desde una perspectiva de género / Gender meanings of the risk of sexually transmitted infections/HIV transmission among young people

Objetivo: Establecer vínculos entre las representaciones sociales que usan los jóvenes para construir su identidad de género, sexualidad y el manejo del riesgo de infecciones de transmisión sexual. Emplazamiento: Diferentes ámbitos de Atención Primaria de Girona. Participantes: Jóvenes de 16 a 21 años (32 en total) residentes en Girona. Método: Estudio cualitativo socioconstrucionista, con muestreo intencional estratificado. Como técnicas de recogida de información se utilizaron grupos triangulares y entrevistas individuales. Los datos fueron analizados usando el análisis sociológico del discurso. Resultados: Entre las chicas, la ideología del amor romántico va asociada a la dependencia de su pareja, resultando en una pérdida de la autonomía en la negociación del uso del preservativo. Los chicos representan su deseo sexual como un instinto que no pueden controlar debido a un hecho biológico como son las hormonas, lo que parece que justifica su despreocupación por el uso del preservativo. Estas creencias explican por qué las chicas son objeto de prejuicios sexistas cuando tienen relaciones sin afecto, mientras que los chicos en estas mismas situaciones aumentan su identidad masculina. El discurso sobre la confianza en la pareja frecuentemente resulta en el rechazo del preservativo, ya que este se asocia a significados no compatibles con la fidelidad. Conclusiones: Estos resultados muestran la necesidad de que los profesionales de la Atención Primaria conozcan la influencia de los procesos psicosociales, especialmente aquellos relacionados con la construcción de las identidades de género y de la sexualidad masculina y femenina, en el manejo de los riesgos asociados con la actividad sexual

Aim: To identify the links between social representations used by young people to construct their gender identity, sexuality, and the risk management for sexually transmitted infections. Setting: Different settings of Primary Health Care in Girona. Participants: Young people aged between 16 and 21 years (32 participants) living in Girona. Method: A qualitative study with a social constructionist perspective. A theoretical sampling was carried out and the triangular group and individual interview techniques were used for data collection. The data was interpreted using discourse analysis. Results: Among girls, the ideology of romantic love was associated with dependence on their partner, resulting in a loss of autonomy in the negotiation of condom use. Boys represented sexual desire as an irrepressible urge that causes a loss of self-control through hormonal impulses, which was used to justify their carelessness in relation to condom use. These perspectives explain why girls are subject to sexist prejudices when they have sex just for physical pleasure in the absence of a stable affective bond, whereas boys in the same situation experience enhanced prestige among their peers that reinforces their male identity. The discourse on trust among couples often results in the rejection of condom use, because condoms encapsulate various meanings that are not compatible with faithfulness. Conclusions: These results show the need for awareness among Primary Care professionals of the influence of psychosocial processes among young people, specifically those related to the construction of gender identity and of male and female sexuality in the management of risks associated with sexual activity

[Gender meanings of the risk of sexually transmitted infections/HIV transmission among young people]. / Percepción del riesgo de infecciones de transmisión sexual/VIH en jóvenes desde una perspectiva de género.

AIM: To identify the links between social representations used by young people to construct their gender identity, sexuality, and the risk management for sexually transmitted infections. SETTING: Different settings of Primary Health Care in Girona. PARTICIPANTS: Young people aged between 16 and 21 years (32 participants) living in Girona. METHOD: A qualitative study with a social constructionist perspective. A theoretical sampling was carried out and the triangular group and individual interview techniques were used for data collection. The data was interpreted using discourse analysis. RESULTS: Among girls, the ideology of romantic love was associated with dependence on their partner, resulting in a loss of autonomy in the negotiation of condom use. Boys represented sexual desire as an irrepressible urge that causes a loss of self-control through hormonal impulses, which was used to justify their carelessness in relation to condom use. These perspectives explain why girls are subject to sexist prejudices when they have sex just for physical pleasure in the absence of a stable affective bond, whereas boys in the same situation experience enhanced prestige among their peers that reinforces their male identity. The discourse on trust among couples often results in the rejection of condom use, because condoms encapsulate various meanings that are not compatible with faithfulness. CONCLUSIONS: These results show the need for awareness among Primary Care professionals of the influence of psychosocial processes among young people, specifically those related to the construction of gender identity and of male and female sexuality in the management of risks associated with sexual activity.

Prolonged Sitting Time: Barriers, Facilitators and Views on Change among Primary Healthcare Patients Who Are Overweight or Moderately Obese.

BACKGROUND AND OBJECTIVES: Prolonged sitting time has negative consequences on health, although the population is not well aware of these harmful effects. We explored opinions expressed by primary care patients diagnosed as overweight or moderately obese concerning their time spent sitting, willingness to change, and barriers, facilitators, goals and expectations related to limiting this behaviour. METHODS: A descriptive-interpretive qualitative study was carried out at three healthcare centres in Barcelona, Spain, and included 23 patients with overweight or moderate obesity, aged 25 to 65 years, who reported sitting for at least 6 hours a day. Exclusion criteria were inability to sit down or stand up from a chair without help and language barriers that precluded interview participation. Ten in-depth, semi-structured interviews (5 group, 5 individual) were audio recorded from January to July 2012 and transcribed. The interview script included questions about time spent sitting, willingness to change, barriers and facilitators, and the prospect of assistance from primary healthcare professionals. An analysis of thematic content was made using ATLAS.Ti and triangulation of analysts. RESULTS: The most frequent sedentary activities were computer use, watching television, and motorized journeys. There was a lack of awareness of the amount of time spent sitting and its negative consequences on health. Barriers to reducing sedentary time included work and family routines, lack of time and willpower, age and sociocultural limitations. Facilitators identified were sociocultural change, free time and active work, and family surroundings. Participants recognized the abilities of health professionals to provide help and advice, and reported a preference for patient-centred or group interventions. CONCLUSIONS: Findings from this study have implications for reducing sedentary behaviour. Patient insights were used to design an intervention to reduce sitting time within the frame of the SEDESTACTIV clinical trial.

Identificación de las competencias actuales y futuras de los profesionales de la salud pública / Current and future competencies for public health professionals

Objetivos: Identificar las competencias actuales y las necesarias para el futuro de los directivos y técnicos de salud pública de Cataluña. Métodos: Investigación cualitativa de perspectiva fenomenológica. Se realizaron 31 entrevistas individuales semiestructuradas a profesionales de la salud pública de Cataluña, entre noviembre de 2009 y febrero de 2010. La muestra fue teórica, intencionada y razonada para incluir la máxima pluralidad discursiva. Se realizó un análisis de contenido temático. Resultados: Se ha obtenido una amplia variedad de competencias actuales y necesarias para el futuro, clasificadas por perfil profesional. Como competencias transversales destaca la necesidad de compartir un marco teórico general sobre la disciplina y la institución. Las más enfatizadas son la gestión del conocimiento, las habilidades comunicativas, el trabajo en equipo interdisciplinario, la orientación intersectorial, los conocimientos jurídicos, las habilidades informáticas y el inglés. Es importante que cada profesional disponga de competencias específicas en su área de actuación. En las competencias específicas hay más diferencias entre técnicos y directivos. Los técnicos priorizan competencias en gestión de recursos humanos y materiales, por las dificultades que se encuentran diariamente. Los directivos dan más importancia a los valores profesionales y organizativos relacionados con la salud pública. Conclusiones: Se requieren competencias transversales, en consonancia con un profesional versátil, y competencias específicas según el ámbito de actuación. Estos resultados confirman que la salud pública es un área de conocimiento multidisciplinario que trabaja estableciendo alianzas y colaboraciones más allá de disciplinas, profesiones y organizaciones (AU)

Objectives: To identify current and future competencies (managers and technicians) for public health professionals in Catalonia (Spain). Methods: Qualitative research with a phenomenological approach. Between November 2009 and February 2010, 31 semistructured interviews were completed with public health professionals working in Catalonia. We purposely used a theoretical sample to include the maximum multiplicity of discourses. We conducted a thematic content analysis. Results: We obtained a wide range of current professional competencies, as well as those required for the future, classified according to professional profile. The participants highlighted transversal competencies, such as the importance of sharing a general theoretical framework of the discipline and the institution. Among the most frequently reported competencies were knowledge management, communication skills, teamwork, multidisciplinary and intersectoral orientation, legal knowledge, computer skills and languages, particularly English. It was also important for individual professionals to have specific skills in their areas of activity. In terms of differences between managers and technicians, the study showed that technicians prioritize management skills concerning human and material resources, while managers emphasize organizational and professional public health expertise. Conclusions: There is a need for transversal and specific competencies in distinct areas. Public health is a multidisciplinary field, which collaborates with a wide range of professionals and organizations (AU)

[Current and future competencies for public health professionals]. / Identificación de las competencias actuales y futuras de los profesionales de la salud pública.

OBJECTIVES: To identify current and future competencies (managers and technicians) for public health professionals in Catalonia (Spain). METHODS: Qualitative research with a phenomenological approach. Between November 2009 and February 2010, 31 semistructured interviews were completed with public health professionals working in Catalonia. We purposely used a theoretical sample to include the maximum multiplicity of discourses. We conducted a thematic content analysis. RESULTS: We obtained a wide range of current professional competencies, as well as those required for the future, classified according to professional profile. The participants highlighted transversal competencies, such as the importance of sharing a general theoretical framework of the discipline and the institution. Among the most frequently reported competencies were knowledge management, communication skills, teamwork, multidisciplinary and intersectoral orientation, legal knowledge, computer skills and languages, particularly English. It was also important for individual professionals to have specific skills in their areas of activity. In terms of differences between managers and technicians, the study showed that technicians prioritize management skills concerning human and material resources, while managers emphasize organizational and professional public health expertise. CONCLUSIONS: There is a need for transversal and specific competencies in distinct areas. Public health is a multidisciplinary field, which collaborates with a wide range of professionals and organizations.

Country of origin and prevention of breast cancer: beliefs, knowledge and barriers.

This study describes the concept of prevention and identifies the knowledge, perceived benefits and barriers, as well as the practices of early detection of breast cancer among women from different cultural backgrounds and socioeconomic levels. A socioconstructivist qualitative study was conducted in Barcelona. The study population consisted of women who were either native (Spanish) or immigrants from low income countries, aged 40 to 69 years. Narrations of the 68 informants were subjected to sociological discourse analysis. Place and culture of origin, social class and the migratory process can either facilitate or constitute barriers to breast cancer prevention.

Knowledge, attitude and perceptions of breast cancer screening among native and immigrant women in Barcelona, Spain.

OBJECTIVE: Inequalities between immigrant and native populations in terms of access and use of health services have been described. The objective is to compare knowledge, attitudes, vulnerabilities, benefits and barriers related to breast cancer (BC) and screening mammography among women from different countries resident in Barcelona. METHODS: A cross-sectional survey carried out in Barcelona in 2009. The study population consisted of female residents in Barcelona between 45 and 69 years of age; participants were Spanish nationals or immigrants from low-income countries. 960 participants were asked 72 questions, mainly with Likert responses. The dependent variables were five quantitative scales: (1) knowledge of BC and early detection, (2) attitude towards health and BC, (3) vulnerability to BC, (4) barriers to mammography, (5) benefits of mammography. The independent variables were country of origin, social class, setting, cohabitation, age, mammography use, length of residence and fluency of the language. Analyses compared scale scores stratified by the independent variables. Multivariable linear regression models were fitted to determine the relationship between the scales and the independent variables. RESULTS: We observed inequalities according to country of origin on all scales after adjustment for independent variables. Chinese women presented the greatest differences with respect to native women, followed by Maghrebi and Filipino women. Inequalities exist on the vulnerability and barriers scales according to social class and urban/rural setting, and on the attitude scale according to social class. CONCLUSIONS: Country of origin, social class and urban/rural setting are key contributors to inequality in these scales.

Effectiveness of antibiotic-lock therapy for long-term catheter-related bacteremia due to Gram-negative bacilli: a prospective observational study.

A prospective observational study evaluated the effectiveness of combining antibiotic-lock therapy and systemic antibiotics for Gram-negative bacilli long-term catheter-related bacteremia. In 46 uncomplicated episodes, the most frequently isolated microorganisms were Pseudomonas aeruginosa (15), Enterobacter cloacae (12), Escherichia coli (10), and Klebsiella spp. (8). Cure was achieved in 95% of cases.

Lipid-lowering drugs in ischaemic heart disease: a quasi-experimental uncontrolled before-and-after study of the effectiveness of clinical practice guidelines.

BACKGROUND: Cardiovascular diseases(CVD), specifically ischaemic heart disease(IHD), are the main causes of death in industrialized countries. Statins are not usually prescribed in the most appropriate way. To ensure the correct prescription of these drugs, it is necessary to develop, disseminate and implement clinical practice guidelines(CPGs), and subsequently evaluate them. The main objective of this study is to evaluate the effectiveness of the implementation of consensual Lipid-lowering drugs (LLD) prescription guidelines in hospital and primary care settings, to improve the control of Low-Density Lipoprotein Cholesterol (LDL-C) levels in patients with IHD in the Terres de l'Ebre region covered by the Catalonian Health Institute. Secondary objectives are to assess the improvement of the prescription profile of these LLDs, to assess cardiovascular morbimortality and the professional profile and participant centre characteristics that govern the control of LDL-C. DESIGN: Quasi-experimental uncontrolled before and after study. The intervention consists of the delivery of training strategies for guideline implementation (classroom clinical sessions and on-line courses) aimed at primary care and hospital physicians. The improvement in the control of LDL-C levels in the 3,402 patients with IHD in our territory is then assessed. SCOPE: Primary care physicians from 11 basic health areas(BHAs) and two hospital services (internal medicine and cardiology). SAMPLE: 3,402 patients registered with IHD in the database of the Catalan Institute of Health(E-cap) before December 2008 and patients newly diagnosed during 2009-2010. VARIABLES: Percentage of patients achieving good control of LDL-C, measured in milligrams per decilitre. The aim of the intervention is to achieve levels of LDL-C < 100 mg/dl in patients with IHD. Secondary variables measure type and time of diagnosis of IHD, type and dose of prescribed cholesterol-lowering drugs, level of physician participation in training activities and their professional profile. DISCUSSION: The development of prescription guidelines previously agreed by various medical specialists involved in treating IHD patients have usually improved drug prescription. The guideline presented in this study aims to improve the control of LDL-C by training physicians through presential and on-line courses on the dissemination of this guideline, and by providing feedback on their personal results a year after this training intervention.

Health policies for migrant populations in three European countries: England; Italy and Spain.

OBJECTIVES: The study aimed at providing a comparative analysis of health policies for immigrant populations in three European countries. METHODS: A descriptive comparative study of health policies for immigrant population was conducted through content analysis. England, Italy and Spain were selected because they have similar national health systems and different histories of immigration. For each country national or regional plans that included health policies for immigrants or ethnic minorities were selected. The analysis was conducted along the following dimensions: policy objectives, strategies, and evaluation of results. Subsequently, strategies were categorized according to the field of action. RESULTS: Improvements in immigrants' health are the ultimate objectives of these policies but they differ in emphasis and strategies. Main strategies relate to: addressing specific health issues; access to healthcare - information, communication, service supply and administrative proceedings; and improving quality of healthcare provision - services adaptation, professionals training and health needs' analysis. Only in England are some results of policy evaluation available. CONCLUSIONS: Different models of immigrant integration in receiving countries seem to condition the health policy approach. England and Spain propose actions to address immigrants' healthcare needs, while in Italy the development of specific strategies is limited.

Estrategias para reclutar mujeres inmigrantes para participar en una investigación cualitativa / Strategies to recruit immigrant women to participate in qualitative research

Objetivo: El objetivo de este trabajo es describir el proceso de selección y reclutamiento de las mujeres de distintos orígenes socioculturales que participaron en una investigación cualitativa, detallando las dificultades encontradas según su procedencia. Métodos: La investigación se realizó en Barcelona durante 2007–2008, con el fin de conocer la influencia de la cultura en la participación en un programa de prevención del cáncer de mama. Resultados: La población de estudio fueron mujeres de 40 a 69 años residentes en Barcelona, autóctonas e inmigrantes procedentes de países en vías de desarrollo. Se planeó el reclutamiento de las participantes mediante múltiples estrategias: informantes clave, mediadoras culturales, personal sanitario, asociaciones, entidades de culto, prensa, carteles informativos, escuelas de adultos y de idiomas, y el padrón de habitantes. Conclusiones: El proceso de captación no se puede limitar a una sola vía, y las asociaciones, entidades de culto y mediadoras culturales son los recursos más eficaces (AU)

Objective: The present article aims to describe the process of selecting and recruiting women from distinct sociocultural backgrounds who participated in a qualitative research project and to outline the difficulties encountered according to the women's origin. Methods: Research was carried out in Barcelona from 2007 to 2008 to identify how culture influences participation in a breast cancer early detection program. Results: The study population consisted of native women and immigrant women from developing countries aged 40 to 69 years old resident in Barcelona. Participants were recruited through multiple strategies: key informants, cultural mediators, healthcare professionals, associations, religious institutions, the media, posters, adult education and language schools, and the population census. Conclusions: The recruitment process cannot be confined to a single source and associations, religion institutions and cultural mediators are the most effective resources (AU)

[Strategies to recruit immigrant women to participate in qualitative research]. / Estrategias para reclutar mujeres inmigrantes para participar en una investigación cualitativa.

OBJECTIVE: The present article aims to describe the process of selecting and recruiting women from distinct sociocultural backgrounds who participated in a qualitative research project and to outline the difficulties encountered according to the women's origin. METHODS: Research was carried out in Barcelona from 2007 to 2008 to identify how culture influences participation in a breast cancer early detection program. RESULTS: The study population consisted of native women and immigrant women from developing countries aged 40 to 69 years old resident in Barcelona. Participants were recruited through multiple strategies: key informants, cultural mediators, healthcare professionals, associations, religious institutions, the media, posters, adult education and language schools, and the population census. CONCLUSIONS: The recruitment process cannot be confined to a single source and associations, religion institutions and cultural mediators are the most effective resources.

Predictors of mortality and impact of aminoglycosides on outcome in listeriosis in a retrospective cohort study.

OBJECTIVES: Gentamicin is often used to treat listeriosis, particularly in patients with meningitis; nonetheless, some clinicians question this practice because of the drug's associated nephrotoxicity and inability to cross the blood-brain barrier. The aim of this study was to evaluate predictors of mortality and the impact of aminoglycosides on outcome in patients with listeriosis. METHODS: We conducted a retrospective study of all non-pregnant adult patients with Listeria monocytogenes infection detected in sterile body fluids between 1983 and 2006. Early mortality was defined as death occurring between days 3 and 14 after admission, and late mortality as in-hospital death after 14 days. RESULTS: Of 118 episodes, 16 were excluded because patients died in the first 48 h. Among the 102 patients analysed, 33 (32%) had received combined beta-lactam and aminoglycoside therapy and 69 (68%) beta-lactam monotherapy. Both groups had similar demographic and clinical features, and rate of appropriate initial therapy. Overall mortality was 21/102 (20.6%). Early overall mortality was 11.8%: 27.3% (9/33) in the combined group and 4.3% (3/69) in the monotherapy group (P = 0.003). Late mortality was 8.8%. In the multivariate analysis, the factors predicting early mortality were renal failure, previous corticosteroid therapy and age >65 years, whereas neoplastic disease and coma were associated with late mortality. Gentamicin administration did not decrease early mortality, but seemed to increase it. In the late mortality analysis, gentamicin use had no impact. In an analysis with the propensity score method for the use of aminoglycosides, combined therapy with this antibiotic was associated with an increasing trend for early mortality (OR 3.40, 95% CI 0.82-14.07). CONCLUSIONS: The addition of aminoglycosides to treatment for listeriosis did not improve the patients' outcome.

Antifungal agents in neonates: issues and recommendations.

Fungal infections are responsible for considerable morbidity and mortality in the neonatal period, particularly among premature neonates. Four classes of antifungal agents are commonly used in the treatment of fungal infections in pediatric patients: polyene macrolides, fluorinated pyrimidines, triazoles, and echinocandins. Due to the paucity of pediatric data, many recommendations for the use of antifungal agents in this population are derived from the experience in adults. The purpose of this article was to review the published data on fungal infections and antifungal agents, with a focus on neonatal patients, and to provide an overview of the differences in antifungal pharmacology in neonates compared with adults. Pharmacokinetic data suggest dosing differences in children versus adult patients with some antifungals, but not all agents have been fully evaluated. The available pharmacokinetic data on the amphotericin B deoxycholate formulation in neonates exhibit considerable variability; nevertheless, the dosage regimen suggested in the neonatal population is similar to that used in adults. More pharmacokinetic information is available on the liposomal and lipid complex preparations of amphotericin B and fluconazole, and it supports their use in neonates; however, the optimal dosage and duration of therapy is difficult to establish. All amphotericin-B formulations, frequently used in combination with flucytosine, are useful for treating disseminated fungal infections and Candida meningitis in neonates. Fluconazole, with potent in vitro activity against Cryptococcus neoformans and almost all Candida spp., has been used in neonates with invasive candidiasis at dosages of 6 mg/kg/day, and for antifungal prophylaxis in high-risk neonates. There are limited data on itraconazole, voriconazole, and posaconazole use in neonates. Caspofungin, which is active against Candida spp. and Aspergillus spp., requires higher doses in children relative to adults, and dosing is best accomplished based on body surface area. Micafungin shows a clear trend toward lower levels in the smallest patients. There are no data on the use of other new antifungal drugs (ravuconazole and anidulafungin) in neonates. In summary, the initial data suggest dosage differences in neonates for some antifungal agents, although the newer agents have not been fully tested for optimal administration in these patients.

[Reasons for attending emergency departments. People speak out]. / Razones para acudir a los servicios de urgencias hospitalarios. La población opina.

OBJECTIVE: To ascertain why people attend hospital emergency departments (ED) for low complexity health problems. METHOD: A phenomenological, interactionist, qualitative study was performed. A theoretical sample that selected one urban and one rural area from Catalonia (Spain) was designed. In each setting, persons (n = 36) who had used the ED or a primary care emergency service 1 month before the beginning of the study were chosen. Data were obtained through 8 focus groups. An interpretative content analysis was performed, and emergent categories were constructed through research triangulation. RESULTS: Five categories emerged: symptoms, whether or not self-diagnosis was involved, perception of needs, awareness of the health services available, and the overall context of the person. Symptoms generated feelings of failing health and thus initiated care seeking. Self-diagnosis determined perceived need and the type of care sought. People contrasted their self-perception of need with their own opinion about the health services available. The decision to go to one or other service was made as a result of this contrast, but the individual's family, work, and social situations also played a part. Informants were more familiar with the service provided by the ED than with that provided by primary care. Time consumption also figured heavily in decision making. CONCLUSIONS: The presence or absence of self-diagnosis is a determining factor in attendance at EDs. Other factors that influence demand are the level of awareness of the health services available, previous experiences, and the life situation of the individual.

Epidemiology, risk factors, and prognosis of Candida parapsilosis bloodstream infections: case-control population-based surveillance study of patients in Barcelona, Spain, from 2002 to 2003.

Candida parapsilosis has emerged as an important yeast species causing fungemia. We describe the incidence and epidemiology of C. parapsilosis fungemia. Data from active population-based surveillance in Barcelona, Spain, from January 2002 to December 2003 were analyzed. We focused on 78 episodes of C. parapsilosis fungemia, and we compared them with 175 Candida albicans controls. C. parapsilosis accounted for 23% of all fungemias. The annual incidences were 1 episode per 10(5) patients, 1.2 episodes per 10(4) discharges, and 1.7 episodes per 10(5) patient days. All isolates but one (99%) were fluconazole susceptible. Seventy-two isolates (92%) were inpatient candidemias. Forty-two episodes (51%) were considered catheter-related fungemia, 35 (45%) were considered primary fungemia, and 3 (4%) were considered secondary fungemia. Risk factors for candidemia were vascular catheterization (97%), prior antibiotic therapy (91%), parenteral nutrition (54%), prior surgery (46%), prior immunosuppressive therapy (38%), malignancy (27%), prior antifungal infection (26%), transplant recipient (16%), neutropenia (12%), and prior colonization (11%). Multivariate analysis of the differential characteristics showed that the factors that independently predicted the presence of C. parapsilosis fungemia were neonate patients (odds ratio [OR], 7.5; 95% confidence interval [CI], 2.1 to 26.8; P = 0.002), transplant recipients (OR, 9.2; 95% CI, 1.9 to 43.3; P = 0.005), patients with a history of prior antifungal therapy (OR, 5.4; 95% CI, 1.8 to 15.9; P = 0.002), and patients who received parenteral nutrition (OR, 2.2; 95% CI, 1.09 to 4.6; P = 0.028). The overall mortality rate was lower than that associated with C. albicans candidemia (23% versus 43%; P < 0.01). In summary, C. parapsilosis was responsible for 23% of all candidemias and was more frequent in neonates, in transplant recipients, and in patients who received parenteral nutrition or previous antifungal therapy, mainly fluconazole. The mortality rate was lower than that associated with C. albicans fungemia.

Antibiotic-lock therapy for long-term intravascular catheter-related bacteraemia: results of an open, non-comparative study.

BACKGROUND: Infection is one of the main problems associated with long-term central venous catheters. This study assesses the effectiveness of antibiotic-lock therapy (ALT) for treating catheter-related bacteraemia (CRB). METHODS: CRB was defined as quantitative blood culture counts through any catheter lumen 5-fold greater than concurrent peripheral blood culture, and qualitative blood culture positive for the same microorganism in all samples. Systemic treatment and ALT were started simultaneously using vancomycin (2000 mg/L) for Gram-positive organisms, and ciprofloxacin or amikacin (2000 mg/L) for Gram-negative bacilli. Heparin was added to ALT. Effectiveness was assessed by clinical and microbiological criteria. Cure was defined as negative blood cultures at both sites without catheter removal at 1 month after the completion of therapy. RESULTS: A total of 115 episodes of CRB in 98 patients were analysed. Catheters were used for chemotherapy (50 episodes), haemodialysis (37), total parenteral nutrition (24) and combined chemotherapy and nutrition (4). Median time from catheter placement to CRB onset was 105 days (IQ range 26-210). Aetiologies included Gram-positive organisms [56 coagulase-negative staphylococci (CoNS), 20 Staphylococcus aureus and 5 other organisms] in 81 episodes (70%), Gram-negative bacilli (11 Escherichia coli, 5 Pseudomonas aeruginosa and 10 other organisms) in 26 (23%) and polymicrobial in 8 (7%). A total of 94 episodes were cured (82%). There were 21 therapeutic failures: 9 S. aureus (1 related death), 9 CoNS, 1 P. aeruginosa, 1 Proteus vulgaris and 1 polymicrobial. Median catheter follow-up in therapeutic success was 168 days (range 7-2740). CONCLUSIONS: ALT combined with systemic antibiotics seems to be effective for treating CRB, especially in Gram-negative and CoNS episodes. S. aureus CRB had an elevated rate of therapeutic failure.

Candidemia in neonatal intensive care units: Barcelona, Spain.

BACKGROUND: Candida spp. are increasingly important hospital-acquired pathogens in neonatal intensive care units (NICU) and cause considerable mortality in preterm infants. Most studies have been limited to a single institution. The aim of this study was to determine the epidemiology of candidemia in all Barcelona NICUs. METHODS: We conducted prospective population-based surveillance for candidemia in Barcelona, Spain, during 2002-2003. This report focuses on the results from 5 participating hospitals with NICUs. RESULTS: We detected 24 cases, resulting in an annual incidence of 32.6 cases per 100,000 live births and 1.1 cases per 100 NICU discharges. Median gestational age was 27.5 weeks (range, 24-40.5), and there were 21 cases among very low birth weight infants. Among the 20 (83%) cases evaluated for the presence of end organ infection, endophthalmitis occurred in 2 cases, and endocarditis, meningitis and peritonitis occurred in 1 case each. Candida parapsilosis was the most frequent species isolated (67%). All isolates were fluconazole-susceptible. Crude mortality was 21%. CONCLUSIONS: The preponderance of C. parapsilosis candidemias observed in Barcelona NICUs is similar to reports from the literature. Morbidity and mortality associated with neonatal candidemia remain high.

Razones para acudir a los servicios de urgencias hospitalarios. La población opina / Reasons for attending emergency departments. People speak out

Objetivo: Conocer por qué las personas acuden a los servicios de urgencia hospitalarios (SUH) por problemas de salud de baja complejidad. Método: Se realizó una investigación cualitativa de tipo fenomenológica interaccionista. La muestra teórica pertenecía a un área urbana y otra rural de Cataluña. Se escogieron personas (n = 36) que habían acudido a los SUH o a servicios de urgencia de la atención primaria de salud (SUAP) en el mes previo a su selección. Se recogieron datos en 8 grupos focales. Se realizó un análisis inductivo descriptivo-interpretativo, construyendo categorías emergentes a partir de la triangulación. Resultados: Emergieron 5 categorías: síntomas, elaboración de autodiagnóstico, percepción de necesidad, conocimiento de la oferta y contexto global de la persona. Los síntomas generan la consideración de pérdida de salud y desencadenan la acción. La elaboración del autodiagnóstico determina la necesidad-tipo de atención. Del contraste entre la percepción-tipo de necesidad y el conocimiento de la oferta de los servicios, así como de la situación vital de la persona, surge la decisión de acudir a un servicio u otro y se genera la acción. El conocimiento de la oferta de los SUH es mejor que el de los SUAP. El tiempo parece básico en la toma de decisiones. Conclusiones: La elaboración de un autodiagnóstico es crítica en la determinación de la acción, pero el conocimiento de la oferta de los servicios, las experiencias previas y la situación vital de la persona modulan el tipo de demanda

Objective: To ascertain why people attend hospital emergency departments (ED) for low complexity health problems. Method: A phenomenological, interactionist, qualitative study was performed. A theoretical sample that selected one urban and one rural area from Catalonia (Spain) was designed. In each setting, persons (n = 36) who had used the ED or a primary care emergency service 1 month before the beginning of the study were chosen. Data were obtained through 8 focus groups. An interpretative content analysis was performed, and emergent categories were constructed through research triangulation. Results: Five categories emerged: symptoms, whether or not self-diagnosis was involved, perception of needs, awareness of the health services available, and the overall context of the person. Symptoms generated feelings of failing health and thus initiated care seeking. Self-diagnosis determined perceived need and the type of care sought. People contrasted their self-perception of need with their own opinion about the health services available. The decision to go to one or other service was made as a result of this contrast, but the individual's family, work, and social situations also played a part. Informants were more familiar with the service provided by the ED than with that provided by primary care. Time consumption also figured heavily in decision making. Conclusions: The presence or absence of self-diagnosis is a determining factor in attendance at EDs. Other factors that influence demand are the level of awareness of the health services available, previous experiences, and the life situation of the individual

Spontaneous pyogenic vertebral osteomyelitis and endocarditis: incidence, risk factors, and outcome.

PURPOSE: The relationship between pyogenic vertebral osteomyelitis and infectious endocarditis is uncertain. This study investigates the incidence and risk factors of infectious endocarditis in patients with pyogenic vertebral osteomyelitis, and the outcome of pyogenic vertebral osteomyelitis with and without associated infectious endocarditis. METHODS: A retrospective record review was conducted of all cases of vertebral osteomyelitis from January 1986 to June 2002, occurring in a tertiary referral hospital. Patients were followed for at least 6 months with careful attention to detection of infectious endocarditis and relapses. RESULTS: Among 606 patients with infectious endocarditis, 28 (4.6%) had pyogenic vertebral osteomyelitis. Among 91 cases of pyogenic vertebral osteomyelitis, 28 (30.8%) had infectious endocarditis. In 6 patients with no clinical signs of infectious endocarditis, the disease was established by routine echocardiography. Infectious endocarditis was more common in patients with predisposing heart conditions and streptococcal pyogenic vertebral osteomyelitis infection. Overall, pyogenic vertebral osteomyelitis in-hospital mortality was 11% (7.1% with infectious endocarditis). Twelve of 25 patients with infectious endocarditis with uncomplicated pyogenic vertebral osteomyelitis were treated for 4 to 6 weeks (endocarditis protocol), with no pyogenic vertebral osteomyelitis relapses. CONCLUSIONS: When specifically sought, the incidence of infectious endocarditis is high in patients with pyogenic vertebral osteomyelitis. Oral therapy may be an option for uncomplicated pyogenic vertebral osteomyelitis; nevertheless, in gram-positive infections, this approach should only be considered after excluding infectious endocarditis. Favorable outcome with shorter treatment in uncomplicated pyogenic vertebral osteomyelitis associated with infectious endocarditis suggests that prolonged therapy may not be needed in this subgroup except for those infected by difficult to treat microorganisms, such as methicillin-resistant Staphylococcus aureus or Candida spp.