[Consensus document for sepsis code implementation and development in the Community of Madrid]. / Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid.

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.

[Cefditoren: a reality for the treatment of community infections]. / Cefditoreno: una realidad para el tratamiento de las infecciones comunitarias.

Cefditoren, a third-generation cephalosporin, is the oral ß-lactam more active against the main community-acquired respiratory tract pathogens (including resistance phenotypes such as penicillin-resistant Streptococcus pneumoniae and ampicillin-resistant Haemophilus influenzae), similar to cefotaxime. Data obtained from clinical trials and later evidence on efficacy and safety, support that cefditoren is an suitable option for the treatment of mild-to moderate community respiratory and urinary tract infections, particularly in regions where non-susceptible phenotipes to common oral antibiotics are prevalent.

Intensity of continuous renal replacement therapies in patients with severe sepsis and septic shock: a systematic review and meta-analysis.

The purpose of this study was to assess the efficacy of continuous renal replacement therapies in patients with severe sepsis or septic shock, with or without acute kidney injury. We performed a systematic search in Medline, Embase, Web of Knowledge, Cochrane Library and Clinicaltrials.gov and a hand search of the retrieved studies. We included both randomised controlled clinical trials and subgroups of randomised trials that assessed the effect of continuous renal replacement therapies (at traditional or high doses) and reported clinical outcomes in adult patients with severe sepsis or septic shock. The study selection and data extraction were performed by duplicate. Analysis of heterogeneity and meta-analysis was performed according to the Cochrane Collaboration guidelines for conducting systematic reviews of interventions. Twelve studies (1895 patients) met the inclusion criteria. Pooling of all studies resulted in a mortality risk ratio of 0.96 (95% confidence interval 0.83 to 1.12). The studies showed moderate statistical heterogeneity (I2 statistic 52%, P = 0.02). The effect on mortality was not modified (interaction P values non significant) by the dose of continuous renal replacement therapies, the severity of illness or the risk of bias. The available evidence suggests that these therapies in patients with severe sepsis or septic shock are not associated with an improvement in other outcomes such as haemodynamics, pulmonary gas exchange, multiple organ dysfunction syndrome or length of stay. The best available evidence does not support the routine use of continuous renal replacement therapies (at traditional or high doses) in patients with severe sepsis or septic shock.

PEEP alta frente a PEEP convencional en el síndrome de distrés respiratorio agudo Revisión sistemática y metaanálisis / High PEEP vs. conventional PEEP in the acute respiratory distress syndrome: a systematic review and meta-analysis

Objetivo. Evaluar, mediante revisión sistemática y metaanálisis, el efecto de presión positiva al final de la espiración (PEEP) alta frente PEEP convencional sobre la mortalidad y riesgo de barotrauma de los pacientes con síndrome de distrés respiratorio agudo (SDRA). Fuente de datos. Búsqueda electrónica en Medline, Embase, CINAHL, CANCERLIT, Pascal-Biomed, ACP Journal Club, biblioteca Cochrane (CDSR, DARE, CCTR), ISI Proceedings, Current Contents y Web of Science y búsqueda manual sobre las referencias seleccionadas. Selección de estudios. Ensayos clínicos controlados aleatorizados publicados tras la NAECC (1994) que evaluaran el efecto de dos niveles de PEEP y que informaran sobre la mortalidad e incidencia de barotrauma. Extracción de datos. Independiente por dos investigadores y las discrepancias se resuelven por consenso en el grupo. Se realizaron las tablas de contingencia y se obtuvieron los riesgos relativos (RR) con los intervalos de confianza (IC) de cada estudio. Resultados. Se seleccionaron 4 artículos para el metaanálisis de mortalidad y 3 para el de barotrauma. No se encontró efecto de ninguno de los niveles de PEEP sobre la mortalidad (RR 0,73, IC 95%: 0,49 a 1,10) ni sobre la incidencia de barotrauma (RR 0,59, IC 95%: 0,14 a 1,73). Sin embargo, analizando los estudios en los que la PEEP se individualizó en función del punto de inflexión (Pflex), se objetiva una reducción significativa de la mortalidad (RR 0,59, IC 95%: 0,43 a 0,82) (p = 0,001). Conclusiones. El empleo de PEEP alta o convencional en función de la oxigenación no afecta a la mortalidad o a la incidencia de barotrauma en pacientes con SDRA. Sin embargo, es posible que exista una reducción de la mortalidad asociada al empleo de PEEP alta individualizada en función de la mecánica pulmonar de cada paciente

Objective. To perform a systematic review and meta-analysis of the literature to evaluate the effects of high PEEP versus conventional PEEP on mortality and on the risk of barotrauma in patients with the acute respiratory distress syndrome (ARDS). Source of data. Computer search of Medline, Embase, CINAHL, CANCERLIT, Pascal-Biomed, ACP Journal Club, Cochrane library (CDSR, DARE, CCTR), ISI Proceedings, Current Contents, and Web of Science, as well as manual search of selected references. Selection of studies. Controlled random clinical trials published after NAECC (1994) that evaluated the effect of two levels of PEEP and that reported the mortality and incidence of barotrauma in the series. Data extraction. By two investigators working independently, with discrepancies resolved by group consensus. Contingency tables were elaborated and the RRs with corresponding confidence intervals were obtained for each study. Results. Four articles were selected for the meta-analysis of mortality and three for the meta-analysis of barotrauma. No effects of PEEP level on mortality were found (RR 0.73, 95% CI: 0.49 to 1.10) or on the incidence of barotrauma (RR 0.50, 95% CI: 0.14 to 1.73). However, an analysis of the studies in which PEEP was individualized in function of Pflex showed a significant decrease in mortality (RR 0.59, 95% CI: 0.43 to 0.82) (p = 0.001) Conclusions. The use of high or conventional PEEP in function of oxygenation does not affect mortality or the incidence of barotrauma in patients with ARDS. However, there might be a decrease in mortality associated to high PEEP individualized in function of the pulmonary mechanics of each patient

[High PEEP vs. conventional PEEP in the acute respiratory distress syndrome: a systematic review and meta-analysis]. / PEEP alta frente a PEEP convencional en el síndrome de distrés respiratorio agudo. Revisión sistemática y metaanálisis.

OBJECTIVE: To perform a systematic review and meta-analysis of the literature to evaluate the effects of high PEEP versus conventional PEEP on mortality and on the risk of barotrauma in patients with the acute respiratory distress syndrome (ARDS). SOURCE OF DATA: Computer search of Medline, Embase, CINAHL, CANCERLIT, Pascal-Biomed, ACP Journal Club, Cochrane library (CDSR, DARE, CCTR), ISI Proceedings, Current Contents, and Web of Science, as well as manual search of selected references. SELECTION OF STUDIES: Controlled random clinical trials published after NAECC (1994) that evaluated the effect of two levels of PEEP and that reported the mortality and incidence of barotrauma in the series. DATA EXTRACTION: By two investigators working independently, with discrepancies resolved by group consensus. Contingency tables were elaborated and the RRs with corresponding confidence intervals were obtained for each study. RESULTS: Four articles were selected for the meta-analysis of mortality and three for the meta-analysis of barotrauma. No effects of PEEP level on mortality were found (RR 0.73, 95% CI: 0.49 to 1.10) or on the incidence of barotrauma (RR 0.50, 95% CI: 0.14 to 1.73). However, an analysis of the studies in which PEEP was individualized in function of Pflex showed a significant decrease in mortality (RR 0.59, 95% CI: 0.43 to 0.82) (p=0.001) CONCLUSIONS: The use of high or conventional PEEP in function of oxygenation does not affect mortality or the incidence of barotrauma in patients with ARDS. However, there might be a decrease in mortality associated to high PEEP individualized in function of the pulmonary mechanics of each patient.

Valor pronóstico de los niveles plasmáticos de troponina en el tromboembolismo pulmonar: una revisión sistemática y metaanálisis / Prognostic value of troponin plasma levels in pulmonary thromboembolism: a systematic review and meta-analysis

Objetivo. Analizar, mediante una revisión sistemática de la literatura, la posible asociación entre los niveles de troponina en el suero y la evolución clínica de los pacientes con tromboembolismo pulmonar. Fuente de datos. Búsqueda de trabajos originales en Medline, Embase, Cochrane Library, Pascal, Medion e ISI Proceedings, y revisión de las referencias de los artículos recuperados. Selección de estudios. Se seleccionaron estudios de cohortes con información sobre los niveles iniciales de troponina y la ocurrencia de mortalidad hospitalaria, evolución clínica desfavorable o sobrecarga ventricular derecha en el ecocardiograma. Extracción de datos. Se obtuvieron por duplicado datos de odds ratio (OR), sensibilidad, especificidad, cocientes de probabilidad (CP), población estudiada, tipo de prueba utilizada y calidad metodológica del estudio. Resultados. Se identificaron 13 estudios, que incluían 1.293 pacientes. Los estudios fueron relativamente homogéneos para cada desenlace, y no se detectaron efecto umbral ni indicios de sesgo de publicación. Los niveles elevados de troponina identificaron a un subgrupo de pacientes con alto riesgo de: fallecer durante la hospitalización (OR 6,20; intervalo de confianza al 95% [IC 95%] 4,04-9,52), presentar signos ecocardiográficos de sobrecarga ventricular derecha (OR 8,04; IC 95% 4,40-16,69) y tener una evolución clínica desfavorable (OR 14,58; IC 95% 6,82-31,16). Los niveles normales de troponina identificaron a pacientes con evolución clínica favorable (CP ponderado 0,23; IC 95% 0,13-0,41). Conclusiones. Los niveles de troponina son útiles para estratificar el riesgo en pacientes con tromboembolismo pulmonar. En el paciente individual, unos niveles normales de troponina indican una alta probabilidad de seguir un curso clínico no complicado

Objective. Analyze possible association between serum troponin levels and clinical evolution of patients with pulmonary thromboembolism through a systematic review of the literature. Data source. Search for original studies in Medline, Embase, Cochrane Library, Pascal, Medion and ISI Proceedings, and review of the references of the recovered articles. Study selection. Cohort studies with information on initial levels of troponin and occurrence of hospital mortality, unfavorable clinical course, or right ventricular overload in the echocardiogram were chosen. Data extraction. Data of the odds radio (OR), sensitivity, specificity, likelihood ratios (LR), population studied, type of test used, and methodology quality of the study were obtained in duplicate. Results. A total of 13 studies, that included 1,293 patients, were identified. The studies were relatively homogeneous for each outcome and no threshold effect or signs of publication bias were detected. Elevated levels of troponin identified a subgroup of patients with high risk of: dying during hospitalization (OR 6.20; 95% CI 4.04-9.52), presenting echocardiographic signs of right ventricular overload (OR 8.04; 95% CI 4.40-16.69) and having an unfavorable clinical course (OR 14.58; 95% CI 6.82-31.16). Normal levels of troponin identified a group of patients with favorable clinical course (LR 0.23; 95% CI 0.13-0.41). Conclusions. Troponin levels are useful to stratify risk in patients with pulmonary thromboembolism. In the individual patient, normal levels of troponin indicate a high likelihood of having an uncomplicated clinical course

Diarrea de origen nosocomial en la población adulta / Nosocomial diarrhoea in the adult population

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Celulitis espontánea recidivante en un paciente con síndrome nefrótico / Recidivant spontaneous cellulitis in a patient with nephrotic syndrome

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