Development of an acute ischemic stroke management course for hospital physicians in emergency departments and intensive care units.

The objective of this study was to evaluate a training course on acute ischemic stroke (AIS) for hospital physicians, part of a regional strategy on AIS patient care. The course comprised an initial self-study (e-Learning) stage and 1-day theoretical-practical course on initial AIS management for Critical Care and Emergency physicians in the Andalusian Health Service (Spain). Data were collected on regional implementation of the stroke code and intravenous thrombolysis treatment. Between 2006 and 2009, 12 courses were attended by 356 physicians from emergency (n=148) and critical care (n=208) departments in the Andalusian health system. The initial stage was failed by 46.4% of trainees; the 1-day AIS course was successfully completed by all trainees, who reported a high satisfaction level. By the end of 2009, all hospitals had adopted the stroke code and approximately 5-6% of patients with AIS received intravenous thrombolysis. This type of healthcare strategy proved effective to improve AIS care in our setting.

Los residentes en las unidades de cuidados intensivos, ¿cuál es su percepción de la formación que reciben? / Residents in an Intensive Care Unit, what perception they have on their training?

Objetivo. Este trabajo intenta responder a la pregunta de cuál es la visión que tienen los residentes de su formación en las unidades de cuidados intensivos (UCI).Sujetos y métodos. Hemos realizado un estudio cualitativo tipo grounded theory. Los participantes son residentes de cualquier especialidad que estuviesen trabajando en las UCI durante el estudio. El diseño tiene tres partes: percepción subjetiva de los residentes de aquellos aspectos que ellos consideran más útiles para su formación, priorización de las actividades regulares más características de las UCI y entrevistas semiestructuradas con informadores claves. Resultados. Nuestro trabajo identifica que los residentes consideran como eje de su formación la práctica clínica a ‘pie de cama’ desarrollada con autonomía y apoyada en una buena tutorización. Paralelamente, otras competencias nucleares como la investigación, la comunicación en situaciones complejas, el trabajo en equipo o la gestión de recursos están infravaloradas, mientras que otras como la seguridad del paciente o la bioética no se han detectado en las respuestas de los residentes. Conclusión. La percepción de los residentes sobre formación durante su estancia en las UCI adolece de algunas carencias, dado que ciertos aspectos claves de la medicina actual no se perciben como prioridades en dicha formación (AU)

Aim. Our work tries to answer the following question: what is the perception of residents on their training in the Intensive Care Units (ICU)?Subjects and methods. We have conducted a qualitative study based on grounded theory. Participants are residents from different specialties working in the ICU of four hospitals of our National Health Service. The study consist of three parts: resident’s subjective perception of those aspects most appreciate in their clinical practice; resident’s prioritizations of routine ICU’s activities, and semi-structured interviews with key informants. Results. According to the resident’s opinions, the clinical practice at the beside of patients, and carried out with autonomy and with a good tutoring support are central to their training; nevertheless some central competencies such as research, difficult communication, team work or resource management are undervalued, while others such as patient safety or bioethics are absent from their comments. Conclusions. Our work highlight that resident’s perception about their training during they compulsory period in ICU has some shortcoming, because some key aspects of current medicine are not perceived as priorities in their training (AU)

Analysis of physiologic alterations in intensive care unit patients and their relationship with mortality.

PURPOSE: To analyze patient physiologic alterations (events) and multiple organ failure during intensive care unit (ICU) stay and examine their relationship with ICU mortality. MATERIAL AND METHODS: A total of 17598 consecutive patients were studied for 10 months (1997-1998) in 55 European ICUs (EURICUS-II). Hourly data were collected on critical and noncritical systolic blood pressure, heart rate, oxygen saturation, and urinary events throughout ICU stay. Sepsis-related Organ Failure Assessment (SOFA) score was collected daily (6409 patients). RESULTS: SAPS-II was 31.2 +/- 18.4 and ICU mortality 13.9%. There were 3.4 +/- 9.2 noncritical (duration, 3.9 +/- 11.4 hours) and 2 +/- 7.5 critical (3.8 +/- 13.1 hours) systolic blood pressure events per patient. Heart rate, oxygen saturation, and urinary events had similar values. Nonsurvivors had significantly more and longer physiologic alterations vs survivors. Mortality was significantly related to mean daily duration of events and mean and maximum daily SOFA. Discrimination capacity to predict ICU mortality was measured using various models: with SAPS II, area under the receiver operating characteristic curve was 0.80; with APACHE III-classified diagnosis added, 0.84; with mean duration of events/ICU day, 0.91; and with mean and maximum SOFA scores, 0.95. CONCLUSION: Routinely gathered ICU data on physiologic variables and multiple organ failure can offer considerable complementary information not provided by usual mortality prediction systems; and their weight in daily care policy decisions may need to be revisited.

Reflexiones sobre los Tribunales de las Oposiciones Universitarias / Thoughs on Competitive Examination for University Professors

La medicina presenta cambios clínicos, terapéuticos, y tecnológicos, coincidiendo con variaciones demográficas culturales y epidemiológicas. Este conjunto de factores y la rapidez con la que se suceden las innovaciones en todos los campos, obliga a replantearse la formación de los médicos, no sólo durante su periodo inicial universitario, sino también a lo largo de toda su vida profesional. Los tribunales de selección de los profesionales que llevarán el peso de la formación universitaria, deben de atender a todas estas dimensiones para asegurar que los futuros profesores transmitan estos valores a los estudiantes. A su vez, los candidatos deben de conocer aquellos puntos sobre los que construir su currículum (AU)

Medicine is undergoing clinical, therapeutic and technological changes, and this is coinciding with demographic, cultural and epidemiological variations. These factors, and the speed with which innovations occur in all fields, requires a rethink of doctors' training, not only during their initial university studies but also throughout their professional life. Those responsible for appointing medical school lecturers must take into account all these aspects in order to ensure that the teaching staff of the future will transmit these values to students. In turn, candidates must be aware of the key aspects around which they should develop their curriculu (AU)

Six-year mortality and quality of life in critically ill patients with chronic obstructive pulmonary disease.

OBJECTIVE: To study the mortality and quality of life (QOL) of survivors at 6 yrs after intensive care unit (ICU) admission for chronic obstructive pulmonary disease. DESIGN: Prospective, multiple-center cohort study. SETTING: A total of 86 ICUs throughout Spain. PATIENTS: Patients in the Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) project with chronic obstructive pulmonary disease were included. MEASUREMENTS AND MAIN RESULTS: The sample comprised 742 patients; 508 of them were admitted for acute exacerbation of chronic obstructive pulmonary disease, and 379 of these required intermittent positive-pressure ventilation. The mean age of the patients was 65.2 +/- 9.89 yrs, Acute Physiology and Chronic Health Evaluation (APACHE) III score was 66.6 +/- 21.04; preadmission QOL questionnaire score was 7 +/- 4.82 points, and hospital mortality was 31.8%. At 6 yrs, 32.2% had died after hospital discharge, 21.6% could not be traced, and 107 patients were alive (18.3% of the 582 followed-up patients). QOL of survivors was worse than preadmission (6.55 +/- 5.6 vs. 4.92 +/- 4.5 points, p < .05), but 72% of patients were self-sufficient. Among the 379 patients admitted to the ICU for acute chronic obstructive pulmonary disease exacerbation and requiring intermittent positive-pressure ventilation, 36.7% died in the hospital; at 6 yrs after hospital discharge, 31.4% had died, 18.7% could not be traced, and 50 patients (16.2% of followed-up patients) were alive. Multivariate analysis with logistic regression showed that the mortality at 6 yrs was related to age (odds ratio, 1.046; 95% confidence interval, 1.023-1.071), APACHE III score (odds ratio, 1.013; 95% confidence interval, 1.001-1.024), and preadmission QOL score (odds ratio, 1.139; 95% confidence interval, 1.078-1.204). CONCLUSION: The 6-yr mortality of patients with chronic obstructive pulmonary disease requiring ICU admission is high. Mortality is mainly influenced by pre-ICU admission QOL. At 6 yrs, at least 15% are alive; survivors have a worse QOL compared with pre-ICU admission, although three quarters of them are self-sufficient.

Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain).

OBJECTIVES: To analyse 1-year mortality and functional disability outcomes and resource use in critical stroke patients admitted to ICU. DESIGN AND SETTING: Multi-centre, prospective, observational study in 28 Spanish hospitals. PATIENTS. Patients admitted for acute stroke from March-August 1999. INTERVENTION: Collection of data on: severity by Apache III and Glasgow Coma Score; neurological lesion, hospital and 1-year mortality; functional disability at 1 year by Barthel Index and Glasgow Outcome Scale; ICU length of stay, life support techniques, and neurosurgical interventions. MEASUREMENT AND RESULTS: We studied 132 patients: 21% with subarachnoid haemorrhage (SAH), 58% intracerebral haemorrhage (ICH), 20% ischaemic stroke (ISC); Apache III 63+/-29 ICU stay 13+/-12 days; 74% required mechanical ventilation. Hospital and 1-year mortality was 33% (22%:ISC, 32%:SAH, 37%:ICH) and 53.8% (66%:ISC, 39%:SAH, 54%:ICH), respectively. Age, APACHE III, and diagnosis defined hospital mortality. Age, APACHE III, and Glasgow Coma Score defined 1-year mortality. Barthel Index score improved ( P<0.001) between discharge and 1 year; 73% of patients presented severe disability at discharge vs. 26% at 1 year; 8% minimal/no disability at discharge vs. 43.3% at 1 year. Only 17% of subarachnoid haemorrhage patients presented severe disability at 1 year. Admission Apache III and hospital-discharge Barthel Index scores were related to functional outcome at 1 year. CONCLUSIONS: Critical stroke patients are characterized by high severity of illness, elevated resource consumption, and poor outcomes that are mainly influenced by severity and age. Glasgow Coma Score-measured neurological severity is the main determinant of future functional capacity, which is greater at 1 year.

Objetivación de la gravedad mediante el sistema APACHE-III aplicado en España / Severity assessment by APACHE III system in Spain

FUNDAMENTO: Evaluar el funcionamiento de la ecuación de predicción del sistema pronóstico APACHE (Acute Physiology, Age and Chronic Health Evaluation) III al aplicarse en España. PACIENTES Y MÉTODO: Estudio prospectivo multicéntrico de cohortes en el que se incluyó a 10.786 pacientes adultos procedentes de 86 unidades de cuidados intensivos españolas. Durante las primeras 24 h del ingreso se recogieron los siguientes datos: variables fisiológicas del Acute Physiology Score (APS), edad, comorbilidades para calcular la puntuación APACHE III; procedencia y diagnóstico principal para aplicar la ecuación de predicción de mortalidad del sistema APACHE III. La variable resultado fue la mortalidad hospitalaria. RESULTADOS: La edad media (desviación estándar) de los pacientes fue 57,74 (0,16) años, un 68 por ciento varones. Los pacientes no quirúrgicos representan el 76 por ciento. La puntuación APACHE III fue 53,75 (0,25); la mortalidad observada y la esperada fueron del 21,3 y el 19,8 por ciento, respectivamente, con una razón estandarizada de mortalidad de 1,07. El estadístico Hosmer-Lemershow obtenido (H) fue 135,6 (C) 133,91 (p < 0,001). El área bajo la curva ROC fue 0,808 y la clasificación correcta para niveles de riesgo del 50 por ciento fue del 82 por ciento. El ajuste de la ecuación fue mejor en diagnósticos no quirúrgicos y en pacientes procedentes de urgencias. La calibración fue buena para riesgos inferiores al 60 por ciento pero infraestimó ligeramente los riesgos observados por encima de este nivel. CONCLUSIONES: La ecucación americana APACHE III se ajusta de forma aceptable al aplicarse a pacientes críticos españoles, pero con limitaciones. Las diferencias en el case-mix de ambas bases de datos podrían explicar las discrepancias encontradas (AU)

Análisis de mortalidad en una unidad de cuidados intensivos neurotraumatológica según el sistema APACHE III / Analysis of mortality according to the APACHE III system in a neurotrauma intensive care unit

Fundamento. Analizar la mortalidad de los pacientes en una UCI neurotraumatológica de un hospital de referencia, en función de la mortalidad esperada según el sistema predictivo APACHE III en su versión española. Métodos. Estudio prospectivo realizado, durante un período de 4 meses, sobre 155 pacientes que ingresaron de forma consecutiva en una UCI neurotraumatológica de un hospital de tercer nivel. Hemos recogido las siguientes variables: edad, sexo, procedencia, diagnóstico de ingreso, comorbilidad, puntuación en el sistema APACHE III y mortalidad hospitalaria. Hemos calculado la probabilidad de muerte esperada según la fórmula española del sistema pronóstico APACHE III, y la hemos comparado con la mortalidad hospitalaria observada, aplicando el test de Hosmer-Lemeshow. Resultados. Los 155 pacientes estudiados tenían una edad de 46 (DE 19) años; el 74,2 por ciento eran varones. Alcanzaron una puntuación APACHE III de 53,5 (33,4) puntos. En cuanto a los diagnósticos, el 48,4 por ciento fueron traumatismos y el 41,9 por ciento eran pacientes neurológicos. Casi la mayoría de los enfermos ingresaron en la UCI procedentes del servicio de urgencias (43,9 por ciento); fueron trasladados desde otro hospital el 29,7 por ciento; procedían de otra planta hospitalaria el 17,4 por ciento, y el resto de pacientes procedían de cirugía. La mortalidad hospitalaria observada fue del 30,9 por ciento, y la predicha por el sistema APACHE III fue del 28,3 por ciento. El test de Hosmer-Lemeshow no demuestra diferencias estadísticamente significativas entre ambas (H = 2,94; NS).Conclusión. La mortalidad en nuestra unidad es similar a la esperada, constatándose la utilidad del sistema predictivo APACHE III, versión española, en los pacientes críticos neurotraumatológicos (AU)

Atención multidisciplinaria del ictus cerebral agudo / Multidisciplinary management of acute brain stroke

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