Development and validation of an alternative procedure for quantitative quality control analysis of 99mTc-radiopharmaceuticals using a Geiger Müller counter.

BACKGROUND AND OBJECTIVES: In a hospital radiopharmacy with 2a operational level, including the preparation of radiopharmaceuticals from prepared and approved reagent kits, it is common to have a single activimeter or dose calibrator for labeling and fractionation, and to perform the quality controls of the 99mTc-radiopharmaceuticals. In certain cases, the accumulation of radioactive material or accidental contamination of the work area causes the background to exceed the limits to carry out the radiochemical purity analyses and it is necessary to look for viable alternatives. In this work, a Geiger Müller detector (equipped with a probe for measuring surface contamination) frequently used for radioprotection purposes, was validated as an alternative and its performance was compared against the activimeter for 99mTc-radiopharmaceuticals. MATERIALS AND METHODS: Using [99mTc]pertechnetate, systematic studies of error analyses and detector response to activity concentration, activity and measurement time were carried out in liquid matrices and in paper. The results were compared against an activimeter calibrated for [99mTc]Tc. RESULTS: The developed method was used to determine the radiochemical purity of the compounds [99mTc]Tc-MDP and [99mTc]Tc-MIBI by ascending paper chromatography tests, obtaining comparable values to those measured with an activimeter in the same system (within 1% uncertainty) and using the method of vial partitioning in a dedicated equipment. CONCLUSIONS: This work demonstrates that a Geiger Müller detector with a probe for measuring surface contamination can be adequately used to replace other equipment in the control of radiochemical purity in the hospital radiopharmacy.

Guía Práctica EsPEN: nutrición enteral domiciliaria / ESPEN practical guideline: Home enteral nutrition

Esta guía práctica de la European Society for Clinical Nutrition and Metabolism (ESPEN) proporciona información a médicos, enfermeras, dietistas, farmacéuticos, cuidadores y otros proveedores de nutrición enteral domiciliaria (NED) de forma concisa, sobre las indicaciones y contraindicaciones de la NED, así como sobre su administración y seguimiento. Esta guía también ofrece información a los pacientes interesados que necesiten NED. La nutrición parenteral domiciliaria no está incluida, pero se abordará en otra guía de la ESPEN. La guía se basa en la guía científica de la ESPEN publicada anteriormente, que consta de 61 recomendaciones (que se han reproducido y renumerado), junto con los comentarios asociados (que se han resumido en relación a la guía científica). Se indican los grados de evidencia y los niveles de consenso. La ESPEN encargó y financió la guía y seleccionó también a los miembros del grupo.(AU)

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providersin a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also informinterested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline isbased on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered,along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels areindicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.(AU)

The beneficial effects of the transanastomotic feeding tube in the management of congenital duodenal obstruction: a meta-analysis.

OBJECTIVE: We aimed to assess the evidence on the efficacy and safety of transanastomotic feeding tubes (TAFTs) in neonates with congenital duodenal obstruction (CDO), we conducted a systematic review. MATERIAL AND METHODS: Using the databases EMBASE, PubMed, and Cochrane, we carried out a thorough literature search up to 2022. Studies comparing TAFT + and TAFT - for CDO were included. We applied a random effect model. RESULTS: 505 CDO patients who met the inclusion criteria were selected. The TAFT + group had a shorter time to reach full feeds (weighted mean difference [WMD]: -6.63, 95% confidence interval [CI]: -8.83 - -4.43; p < 0.001) and had significantly less central venous catheter (CVC) insertion (I2 = 85%) (RR: 0.43, 95% CI: 0.19-1.00; p < 0.05). Fewer patients in the TAFT + group received parenteral nutrition (PN) (I2 = 78%) (RR: 0.43, 95% CI: 0.20-0.95; p < 0.05). There was no statistically significant difference in terms of the development of sepsis (I2 = 37%) (risk ratio [RR]: 1.35, 95% CI: 0.52-3.46; p > 0.05). No statistically significant difference was observed in terms of length of stay (I2 = 82%) (WMD: 2.22, 95% CI: -7.59-12.03; p > 0.05) and mortality (I2 = 0%) (RR: 0.55, 95% CI: 0.07-4.34; p > 0.05). CONCLUSIONS: The use of the transanastomotic tube resulted in early initiation of full feeding, less CVC insertion, and less need for PN.

OBJETIVO: Nuestro objetivo fue evaluar la evidencia sobre la eficacia y seguridad de TAFT en recién nacidos con CDO, realizamos una revisión sistemática. MATERIAL Y MÉTODOS: Utilizando las bases de datos EMBASE, PubMed y Cochrane, realizamos una búsqueda bibliográfica exhaustiva hasta 2022. Se incluyeron estudios que compararan TAFT + y TAFT - para CDO. Aplicamos un modelo de efectos aleatorios. RESULTADOS: Se seleccionaron 505 pacientes con ODC que cumplían con los criterios de inclusión. El grupo TAFT + tuvo un tiempo más corto para alcanzar la alimentación completa (DMP -6.63, IC del 95 %: −8.83 a −4.43; p < 0.001) y tuvo una inserción de CVC significativamente menor. Menos pacientes en grupo TAFT + recibieron NP (I2 = 78%) (RR: 0.43, IC del 95%: 0.20 a 0.95; p < 0.05). No hubo diferencia estadísticamente significativa en cuanto al desarrollo de sepsis. No se observaron diferencias estadísticamente significativas en cuanto a la duración de la estancia (I2 = 82 %) (DMP 2.22, IC del 95 %: −7.59 a 12.03; p < 0.05) y mortalidad (I2=0 %) (RR: 0.55, IC del 95 % 0.07 a 4.34; p > 0.05). CONCLUSIONES: El uso de la sonda transanastomótica resultó en el inicio temprano de la alimentación completa, menor inserción de CVC y menor necesidad de NP.

[ESPEN practical guideline: Home enteral nutrition]. / Guía Práctica ESPEN: nutrición enteral domiciliaria.

Introduction: This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

Introducción: Esta guía práctica de la European Society for Clinical Nutrition and Metabolism (ESPEN) proporciona información a médicos, enfermeras, dietistas, farmacéuticos, cuidadores y otros proveedores de nutrición enteral domiciliaria (NED) de forma concisa, sobre las indicaciones y contraindicaciones de la NED, así como sobre su administración y seguimiento. Esta guía también ofrece información a los pacientes interesados que necesiten NED. La nutrición parenteral domiciliaria no está incluida, pero se abordará en otra guía de la ESPEN. La guía se basa en la guía científica de la ESPEN publicada anteriormente, que consta de 61 recomendaciones (que se han reproducido y renumerado), junto con los comentarios asociados (que se han resumido en relación a la guía científica). Se indican los grados de evidencia y los niveles de consenso. La ESPEN encargó y financió la guía y seleccionó también a los miembros del grupo.

Proceso que vive el paciente quirúrgico abdominal al recibir soporte nutricional artificial / Process experienced by the abdominal surgical patient receiving artificial nutritional support / Processo vivenciado pelo paciente cirúrgico abdominal que recebe suporte nutricional artificial

Introducción: La persona en postoperatorio de cirugía abdominal puede llegar a presentar complicaciones a causa de la patología quirúrgica de base o por la cirugía, impidiendo iniciar o tolerar la vía oral. Una medida que se toma para prevenir o tratar la desnutrición hospitalaria es el manejo con soporte nutricional artificial, evento que transforma la forma de percibir y vivir el proceso de alimentación. Objetivo: comprender el proceso que vive la persona adulta al recibir soporte nutricional artificial en el postoperatorio de cirugía abdominal. Materiales y métodos: se empleó la metodología cualitativa, teoría fundamentada, según postulados de Corbin y Strauss. Se realizaron entrevistas a profundidad a 21 personas adultas en postoperato-rio de cirugía abdominal y manejo con soporte nutricional artificial. Resultados: del análisis de los datos se establecieron 4 etapas del proceso: presentando dificultad para alimentarse, estando desnutrido o en riesgo nutricional, recibiendo el soporte nutricional artificial y anhelando recu-perar la normalidad de la vida. Conclusiones: el proceso tiene un punto de inicio, determinado por las manifestaciones de la enfermedad, luego el paciente pasa a recibir soporte de nutrición artificial, situación que les genera miedo y ansiedad, continúa con la aceptación y el reconoci-miento de los beneficios de la nutrición artificial y finaliza con el inicio de la vía oral.

Introduction: the person in the postoperative period of abdominal surgery may present com-plications due to the underlying surgical pathology or due to the surgery, preventing them from starting or tolerating the oral route. A measure that is taken to prevent or treat hospital malnutrition is management with artificial nutritional support, an event that transforms the way of perceiving and experiencing the feeding process. Objective: to understand the process experienced by adults receiving artificial nutritional support in the postoperative period of ab-dominal surgery. Materials and methods: qualitative methodology was used, fundamental theory, according to Corbin and Strauss postulates. In-depth interviews were conducted with 21 postoperative adults after abdominal surgery and management with artificial nutritional support. Results: From the analysis of the data, 4 stages of the process were established: pre-senting difficulty feeding, malnourished or at nutritional risk, receiving artificial nutritional support and longing to return to normal life.NConclusions: the process has a starting point, determined by the manifestations of the disease, then the patient begins to receive artificial nutrition support, a situation that generates fear and anxiety, continues with the acceptance and recognition of the benefits of nutrition. artificial and ends with the beginning of the oral route

Introdução: A pessoa em pós-operatório de cirurgia abdominal pode apresentar complicações decorrentes da patologia cirúrgica de base ou decorrentes da cirurgia, impedindo-a de iniciar ou tolerar a via oral. Uma medida adotada para prevenir ou tratar a desnutrição hospitalar é o manejo com suporte nutricional artificial, evento que transforma a forma de perceber e vivenciar o processo de alimentação. Objetivo: compreender o processo vivenciado por adultos que re-cebem suporte nutricional artificial no pós-operatório de cirurgia abdominal. Materiais e méto-dos: foi utilizada a metodologia qualitativa, grounded theory, segundo os postulados de Corbin e Strauss. Foram realizadas entrevistas em profundidade com 21 adultos no pós-operatório de ciru-rgia abdominal e manejo com suporte nutricional artificial. Resultados: A partir da análise dos dados foram estabelecidas 4 etapas do processo: apresentar dificuldade para se alimentar, estar desnutrido ou em risco nutricional, receber suporte nutricional artificial e desejar retornar à vida normal. Conclusões: o processo tem um ponto de partida, determinado pelas manifestações da doença, então o paciente começa a receber suporte nutricional artificial, situação que gera medo e ansiedade, continua com a aceitação e reconhecimento dos benefícios da nutrição artificial e termina com o início da via oral

Diagnóstico de imagem radiológica como protocolo de certificação na prevenção de eventos adversos após sondagem naso/oro enteral / Diagnosis of radiological imaging as a certification protocol in the prevention of adverse events after naso/enteral oro probing / Diagnóstico de la imagen radiológica como protocolo de certificación en la prevención de eventos adversos tras el sondeo naso/enteral oro

Objetivo. Apontar para a forma como a sonda nasoenteral serve a várias finalidades, entre as quais estão a própria alimentação enteral, a administração de drogas, como meio de contraste ou carvão ativado, para fins de aspiração do conteúdo do estômago para descomprimir o estômago de fluido, ar ou sangue, para reduzir o risco de vômito ou aspiração e para outros fins. Método: Revisão de literatura, descritiva exploratória, escolhidas, pois descreve, discute e analisa de forma ampla a literatura publicada sobre o tema, sob o ponto de vista teórico ou contextual a respeito da relevância do diagnóstico por imagem radiológica nestes casos. Resultados: Deve-se garantir a segurança do paciente, para isso é essencial confirmar que a sonda foi introduzida de maneira correta e está no devido local (estômago ou parte do intestino), uma vez que a sonda pode inadvertidamente ter sido inserida nos pulmões, o que pode passar desapercebido em pacientes de alto risco. Conclusão: Deve-se usar a sonda naso/oro para terapia nutricional, além de se prevenir eventos adversos para que o processo seja efetivo.

Objective. Point out how the nasoenteral tube serves various purposes, among which are enteral feeding itself, administration of drugs such as contrast medium or activated charcoal, for the purpose of aspiration of stomach contents to decompress the stomach of fluid, air or blood, to reduce the risk of vomiting or aspiration, and for other purposes. Method: Literature review, descriptive and exploratory, chosen because it describes, discusses and analyzes widely the published literature on the subject, from a theoretical or contextual point of view regarding the relevance of radiological imaging diagnosis in these cases. Results: Patient safety must be ensured, for this it is essential to confirm that the tube has been inserted correctly and is in the right place (stomach or part of the intestine), since the tube may have been inadvertently inserted into the lungs, which may go unnoticed in high-risk patients. Conclusion: The naso/oro tube should be used for nutritional therapy, in addition to preventing adverse events for the process to be effective

Objetivo. Señalar cómo la sonda nasoenteral sirve para varios fines, entre los que se encuentran la alimentación enteral en sí, la administración de fármacos como medio de contraste o carbón activado, con el fin de aspirar el contenido del estómago para descomprimir el estómago de líquido, aire o sangre, para reducir la riesgo de vómito o aspiración, y para otros fines. Método: Revisión bibliográfica, descriptiva y exploratoria, elegida porque describe, discute y analiza ampliamente la literatura publicada sobre el tema, desde un punto de vista teórico o contextual respecto a la relevancia del diagnóstico por imágenes radiológicas en estos casos. Resultados: Se debe garantizar la seguridad del paciente, para ello es fundamental confirmar que la sonda se ha insertado correctamente y está en el lugar correcto (estómago o parte del intestino), ya que la sonda puede haber sido introducida inadvertidamente en los pulmones, que puede pasar desapercibido en pacientes de alto riesgo. Conclusión: La sonda naso/oro debe ser utilizada para la terapia nutricional, además de prevenir eventos adversos para que el proceso sea efectivo.

Measuring saccades in patients with Niemann-Pick type C: A comparison between video-oculography and a novel eye tracking test based on continuous psychophysics.

Introduction: Vertical supranuclear gaze palsy is a key feature of Niemann-Pick type C (NP-C) and is commonly quantified using video-oculography (VOG). VOG requires sitting still for long times and performing specific tasks, thus it can be challenging or impossible for patients severely affected by movement disorders or cognitive impairment. To overcome this limitation, we measure saccades of NP-C patients using a fast eye tracking test based on continuous psychophysics and compare it to VOG. Methods: Saccades of six NP-C patients and six age-matched controls were assessed using VOG and Standardized Oculomotor and Neuro-ophthalmic Disorders Assessment (SONDA). In SONDA, participants continuously track a semi-randomly moving dot on a computer screen while their gaze is being tracked. For both assessments, saccades were quantified using four conventional measures: amplitude, gain, latency, and peak velocity. Furthermore, SONDA's continuous measures were quantified with several novel spatio-temporal properties. Results: In the NP-C patients, both methods revealed reduced amplitude, gain, peak velocity, and increased latency of vertical saccades compared to horizontal saccades and compared to healthy controls. Effect sizes obtained with SONDA were overall larger than those for VOG. SONDA's spatio-temporal properties showed similar trends. Conclusion: SONDA reveals a deterioration of vertical saccades in NP-C patients that is consistent with VOG. SONDA's measures based on continuous psychophysics are consistent with traditional saccadic parameters and can potentially provide complementary information. SONDA shows larger effect sizes than VOG, suggesting that it provides robust and clinically relevant outcomes with a more intuitive task and shorter testing time.

[Evaluation of the use of nasal bridle in clinical practice]. / Evaluación del uso de la brida nasal en la práctica habitual.

Introduction: Introduction: the nasal bridle (NB) is one of the strategies to avoid the displacement of tubes for enteral nutrition (EN) used during a nutritional intervention. Objectives: to review the efficacy and safety of NB placement in a patient population requiring EN by tube feeding. To analyze their clinical characteristics and identify complications related to this procedure. Methods: a retrospective observational study in usual clinical practice including patients admitted to a second-level hospital with EN catheters who required the use of a commercial NB-CORGRIP NG/NI TFEEDING TUBE RETENTION SYSTEM. Results: 51 patients with a mean age of 73 years (37-96) were analyzed; 64.7 % were men. Oropharyngeal dysphagia (OPD) was the fundamental indication for placement of an EN tube (54.9 %) followed by refusal to ingest (17.6 %), and orotracheal intubation (7.8 %), among others. NB was withdrawn in 7.8 % of cases due to change in digestive access (gastrostomy), in 21.6 % because of transition to the oral route, and in 9.8 % due to ignorance on how to use it. We found significant differences between accidental removal and self-withdrawal of probes before and after BN placement (2.59 ± 1.512 vs 0.24 ± 0.596; p < 0.05). No related complications were recorded except for only one case of skin ulcer. Conclusions: NB is a safe and effective retention system for the prevention of probe displacement and withdrawal in patients with a wide variety of pathologies. Training health professionals is essential for proper use.

Introducción: Introducción: la brida nasal (BN) es una de las estrategias para evitar el desplazamiento de las sondas para nutrición enteral (NE) utilizadas en el curso de una intervención nutricional. Objetivos: revisar la eficacia y la seguridad de la colocación de la BN en una población de pacientes que precisan NE por sonda. Analizar sus características clínicas e identificar las complicaciones relacionadas con este procedimiento. Métodos: estudio observacional, retrospectivo en condiciones de práctica clínica habitual, incluyendo pacientes ingresados en un hospital de segundo nivel, portadores de sonda para NE, que hayan precisado la utilización de un sistema comercial CORGRIP NG/NI TFEEDING TUBE RETENTION SYSTEM de BN. Resultados: se analizan 51 pacientes con una edad media de 73 años (37-96); el 64,7 % eran varones. La disfagia orofaringea (DOF) fue la indicación fundamental para la colocación de la sonda de NE (54,9 %), seguida del rechazo de la ingesta (17,6 %) y la intubación orotraqueal (7,8 %), entre otras. La BN fue retirada en el 7,8 % de los casos por cambio de acceso digestivo (gastrostomía), en el 21,6 % por paso a la vía oral y en el 9,8 % por desconocimiento de su manejo. Evidenciamos diferencias significativas entre los arrancamientos accidentales y las autorretiradas de las sondas antes y después de la colocación de la BN (2,59 ± 1,512 vs. 0,24 ± 0,596; p < 0,05). No se registraron complicaciones relacionadas salvo un caso de úlcera cutánea. Conclusiones: la BN es un sistema de retención seguro y eficaz en la prevención de desplazamientos y retiradas de la sonda en los pacientes con amplia variedad de patologías. Formar a los profesionales sanitarios es imprescindible para su adecuada utilización.

Pharmaceutical care at discharge for patients with feeding tubes.

Introduction: Objective: to assess and analyse a medication adaptation pathway for feeding tube administration followed by clinical pharmacists for patients at discharge, and to analyse the level of physician acceptance of the recommendations issued by pharmacists in pharmaceutical care reports to improve patient therapy. Methods: a multidisciplinary protocol for treatment adaptation to feeding tube administration at discharge was implemented in a 350-bed hospital during 2019, in which pharmacists prepared feeding tube medication-adaptation reports during pharmaceutical care visits. The number of recommendations related to adaptation of a drug to route of administration was recorded and classified as need for change of active substance or change of pharmaceutical form. Physician acceptance of pharmacist recommendations was analysed in a one-year retrospective observational study. Results: a total of 66 pharmaceutical care visits were recorded for 57 patients (1.2 visits per patient). In 47 of these 66 visits (71.2 %), at least one drug modification was required in a patient prescription, and the median number of drugs per patient needing to be modified was 2. Overall, 93 of the 489 prescribed drugs (19.0 %) required some changes to be suitable for administration via feeding tube: change of active substance in 52.7 % (49/93) of cases, and change of pharmaceutical form in 47.3 % (44/93) of cases. The physicians' level of acceptance of recommendations was 43.0 % (40/93), and change of pharmaceutical form was less accepted than change of active substance. Conclusion: the inclusion of clinical pharmacists in multidisciplinary teams leads to an improvement in adapting medication to feeding tube administration, but also shows a lack of communication or understanding of pharmacist recommendations by physicians resulting in a low rate of prescription changes.

Introducción: Objetivo: evaluar y analizar un circuito de adaptación de la medicación para la administración por sonda de alimentación llevado a cabo por farmacéuticos clínicos para pacientes al alta, y analizar el nivel de aceptación por parte de los médicos de las recomendaciones emitidas por los farmacéuticos en los informes de atención farmacéutica para mejorar la terapia de los pacientes. Métodos: durante el año 2019 se implementó en un hospital de 350 camas un protocolo multidisciplinario de adaptación del tratamiento para la administración por sonda de alimentación al alta, en el cual los farmacéuticos elaboraron informes de adaptación de la medicación por sonda de alimentación durante las visitas de atención farmacéutica. Se registró el número de recomendaciones relacionadas con la adecuación del fármaco a la vía de administración y se clasificaron como necesidad de cambio de principio activo o cambio de forma farmacéutica. La aceptación de las recomendaciones de los farmacéuticos por parte de los médicos se analizó en un estudio observacional retrospectivo de un año. Resultados: se registraron un total de 66 visitas de atención farmacéutica para 57 pacientes (1,2 visitas por paciente). En 47 de estas 66 visitas (71,2 %) se requirió al menos una modificación de medicamentos en la prescripción de los pacientes, y la mediana de medicamentos por paciente que necesitaban modificarse fue de 2. En total, 93 de los 489 medicamentos prescritos (19,0 %) requirió algunos cambios para ser aptos para la administración por sonda: cambio de principio activo en el 52,7 % (49/93) de los casos y cambio de forma farmacéutica en el 47,3 % (44/93) de los casos. El nivel de aceptación de las recomendaciones por parte de los médicos fue del 43,0 % (40/93), siendo menos aceptado el cambio de forma farmacéutica que el cambio de principio activo. Conclusión: la inclusión de farmacéuticos clínicos en equipos multidisciplinarios conduce a una mejora en la adaptación de la medicación a la administración por sonda de alimentación, pero también muestra que existe una falta de comunicación o comprensión de las recomendaciones de los farmacéuticos por parte de los médicos, lo que resulta en una baja tasa de cambios en la prescripción.

Evaluación del uso de la brida nasal en la práctica habitual / Evaluation of the use of nasal bridle in clinical practice

Introducción: la brida nasal (BN) es una de las estrategias para evitar el desplazamiento de las sondas para nutrición enteral (NE) utilizadas en el curso de una intervención nutricional. Objetivos: revisar la eficacia y la seguridad de la colocación de la BN en una población de pacientes que precisan NE por sonda. Analizar sus características clínicas e identificar las complicaciones relacionadas con este procedimiento. Métodos: estudio observacional, retrospectivo en condiciones de práctica clínica habitual, incluyendo pacientes ingresados en un hospital de segundo nivel, portadores de sonda para NE, que hayan precisado la utilización de un sistema comercial CORGRIP NG/NI TFEEDING TUBE RETENTION SYSTEM de BN. Resultados: se analizan 51 pacientes con una edad media de 73 años (37-96); el 64,7 % eran varones. La disfagia orofaringea (DOF) fue la indicación fundamental para la colocación de la sonda de NE (54,9 %), seguida del rechazo de la ingesta (17,6 %) y la intubación orotraqueal (7,8 %), entre otras. La BN fue retirada en el 7,8 % de los casos por cambio de acceso digestivo (gastrostomía), en el 21,6 % por paso a la vía oral y en el 9,8 % por desconocimiento de su manejo. Evidenciamos diferencias significativas entre los arrancamientos accidentales y las autorretiradas de las sondas antes y después de la colocación de la BN (2,59 ± 1,512 vs. 0,24 ± 0,596; p < 0,05). No se registraron complicaciones relacionadas salvo un caso de úlcera cutánea. Conclusiones: la BN es un sistema de retención seguro y eficaz en la prevención de desplazamientos y retiradas de la sonda en los pacientes con amplia variedad de patologías. Formar a los profesionales sanitarios es imprescindible para su adecuada utilización. (AU)

Introduction: the nasal bridle (NB) is one of the strategies to avoid the displacement of tubes for enteral nutrition (EN) used during a nutritional intervention. Objectives: to review the efficacy and safety of NB placement in a patient population requiring EN by tube feeding. To analyze their clinical characteristics and identify complications related to this procedure. Methods: a retrospective observational study in usual clinical practice including patients admitted to a second-level hospital with EN catheters who required the use of a commercial NB—CORGRIP NG/NI TFEEDING TUBE RETENTION SYSTEM. Results: 51 patients with a mean age of 73 years (37-96) were analyzed; 64.7 % were men. Oropharyngeal dysphagia (OPD) was the fundamental indication for placement of an EN tube (54.9 %) followed by refusal to ingest (17.6 %), and orotracheal intubation (7.8 %), among others. NB was withdrawn in 7.8 % of cases due to change in digestive access (gastrostomy), in 21.6 % because of transition to the oral route, and in 9.8 % due to ignorance on how to use it. We found significant differences between accidental removal and self-withdrawal of probes before and after BN placement (2.59 ± 1.512 vs 0.24 ± 0.596; p < 0.05). No related complications were recorded except for only one case of skin ulcer. Conclusions: NB is a safe and effective retention system for the prevention of probe displacement and withdrawal in patients with a wide variety of pathologies. Training health professionals is essential for proper use. (AU)

Pharmaceutical care at discharge for patients with feeding tubes / Atención farmacéutica al alta para pacientes con sondas de alimentación

Objective: to assess and analyse a medication adaptation pathway for feeding tube administration followed by clinical pharmacists for patients at discharge, and to analyse the level of physician acceptance of the recommendations issued by pharmacists in pharmaceutical care reports to improve patient therapy. Methods: a multidisciplinary protocol for treatment adaptation to feeding tube administration at discharge was implemented in a 350-bed hospital during 2019, in which pharmacists prepared feeding tube medication-adaptation reports during pharmaceutical care visits. The number of recommendations related to adaptation of a drug to route of administration was recorded and classified as need for change of active substance or change of pharmaceutical form. Physician acceptance of pharmacist recommendations was analysed in a one-year retrospective observational study. Results: a total of 66 pharmaceutical care visits were recorded for 57 patients (1.2 visits per patient). In 47 of these 66 visits (71.2 %), at least one drug modification was required in a patient prescription, and the median number of drugs per patient needing to be modified was 2. Overall, 93 of the 489 prescribed drugs (19.0 %) required some changes to be suitable for administration via feeding tube: change of active substance in 52.7 % (49/93) of cases, and change of pharmaceutical form in 47.3 % (44/93) of cases. The physicians’ level of acceptance of recommendations was 43.0 % (40/93), and change of pharmaceutical form was less accepted than change of active substance. (AU)

Objetivo: evaluar y analizar un circuito de adaptación de la medicación para la administración por sonda de alimentación llevado a cabo por farmacéuticos clínicos para pacientes al alta, y analizar el nivel de aceptación por parte de los médicos de las recomendaciones emitidas por los farmacéuticos en los informes de atención farmacéutica para mejorar la terapia de los pacientes. Métodos: durante el año 2019 se implementó en un hospital de 350 camas un protocolo multidisciplinario de adaptación del tratamiento para la administración por sonda de alimentación al alta, en el cual los farmacéuticos elaboraron informes de adaptación de la medicación por sonda de alimentación durante las visitas de atención farmacéutica. Se registró el número de recomendaciones relacionadas con la adecuación del fármaco a la vía de administración y se clasificaron como necesidad de cambio de principio activo o cambio de forma farmacéutica. La aceptación de las recomendaciones de los farmacéuticos por parte de los médicos se analizó en un estudio observacional retrospectivo de un año. Resultados: se registraron un total de 66 visitas de atención farmacéutica para 57 pacientes (1,2 visitas por paciente). En 47 de estas 66 visitas (71,2 %) se requirió al menos una modificación de medicamentos en la prescripción de los pacientes, y la mediana de medicamentos por paciente que necesitaban modificarse fue de 2. En total, 93 de los 489 medicamentos prescritos (19,0 %) requirió algunos cambios para ser aptos para la administración por sonda: cambio de principio activo en el 52,7 % (49/93) de los casos y cambio de forma farmacéutica en el 47,3 % (44/93) de los casos. El nivel de aceptación de las recomendaciones por parte de los médicos fue del 43,0 % (40/93), siendo menos aceptado el cambio de forma farmacéutica que el cambio de principio activo. (AU)

Evaluación diafragmática mediante ecografía: repaso de una técnica imprescindible para el neumólogo / Diaphragmatic evaluation by ultrasound: review of an essential technique for the pulmonologist

La ecografía clínica es una herramienta de uso cada vez más extendido. En el campo de la patología respiratoria, esta técnica también se ha incluido de forma progresiva en la práctica habitual, hasta abarcar en los últimos años la patología diafragmática. No solo tiene una curva de aprendizaje sencilla, sino que es accesible e indolora. El objetivo es realizar una revisión detallada de la técnica y analizar su utilidad, sobre todo en el campo de la ventilación mecánica y el paciente neuromuscular.(AU)

Clinical ultrasound is an increasingly widespread tool. In the field of respiratory pathology, this technique has also been progressively included in our usual practice even encompassing diaphragmatic pathology in recent years. Not only does it have an easy learning curve, but it is also accessible and painless. The objective is to perform a detailed review of the technique and analyze its usefulness, especially in the field of mechanical ventilation and neuromuscular patients.(AU)

Infección urinaria producida por enterococo faecalis y enterococo faecium asociada a sonda vesical: factores de riesgo y evaluación de los patrones de resistencia / Urinary infection produced by enterococcus faecalis and enterococcus faecium associated with bladder catheterization: risk factors and evaluation of resistance patterns

Background and objectives: Urinary tract infection (UTI) is one of the most common infections in hospitalized and outpatients. Bladder catheterization is an important risk factor. The increase in antibiotic resistance can make the treatment of these infections a challenge. The main objective of this study is to analize the resistance and sensitivity rates of UTIs in catheterized patients caused by Enterococcus (E.faecium and E.faecalis). Associated riskfactors were also studied. Materials and methods: Retrospective observational study of patients with urinary infection associated to catheterization caused by E.faecium and E.faecalis during 2020 in al Internal Medicina Unit. Results: Ampicillin was the antibiotic with the highest resistance rate in the case of E.faecium (94.4%), while 93.05% of E.faecalis presented resistance to Gentamicin. Teicoplanin and Vancomycin were the ones with the lowest rates. Regarding risk factors, dementia, catheterization > 5 days, previous antibiotic therapy, immunosuppresion, and institutionalized patients were statistically significant. Conclusions: It is important to know the epidemiology of UTIs in each area, as well as the raties of resistance and risk factors in order to provide the most adequate treatment possible, and to avoid the increase in resistance. (AU)

Introducción y objetivos: La infección urinaria es una de las infecciones intra y extrahospitalarias más frecuentes, siendo el sondaje vesical uno de los principales factores de riesgo. El aumento de resistencias antibióticas al que estamos asistiendo hace que su tratamiento a veces suponga un reto. El objetivo principal del estudio pretende analizar las tasas de resistencia y sensibilidad de las principales infecciones urinarias producidas por Enterococos (E.faecium y E.faecalis) en pacientes sondados. También se estudiaron los factores de riesgo asociados. Material y métodos: Estudio retrospectivo observacional de pacientes con infección urinaria asociada a sondaje por E.faecium y E.faecalis durante el año 2020 en un servicio de Medicina Interna. Resultados: La ampicilina fue el antibiótico que mayor tasa de resistencia obtuvo en el caso de E.faecium (94.4%), mientras que el 93.05% de casos por E.faecalis presentó resistencias a gentamicina. Teicoplanina y vancomicina fueron los que menores tasas tuvieron. En cuanto a los factores de riesgo, la demencia, el sondaje > 5 días, la antibioterapia previa, la inmunodepresión y los pacientes institucionalizados fueron estadísticamente significativos. Conclusiones: Es importante conocer la epidemiología de las infecciones urinarias de la zona por áreas geográficas, así como las tasas de resistencias y los factores de riesgo con el fin de un tratamiento lo más adecuado posible, y evitar el aumento de resistencias. (AU)

Tubularización e incisión de la placa uretral para reparación de hipospadias distal primario en 473 casos: evaluación de los resultados según la cobertura y el tipo de sonda / Tubularized incised plate repair in 473 primary distal hypospadias cases: an evaluation of outcomes according to coverages and stent types

Objetivo: Hemos empleado previamente la técnica de reparación mediante tubularización e incisión de la placa uretral (TIP) con algunas modificaciones en casos de hipospadias distal debido a sus excelentes resultados cosméticos. En este estudio se evaluaron los efectos de la espongioplastia y los colgajos de dartos dorsal y de las sondas uretrales cortas en los resultados de la reparación con TIP.Materiales y método: Sólo se incluyeron casos de hipospadias distal. Los pacientes elegibles se dividieron en dos grupos: el grupo A incluyó a los pacientes con reparación mediante espongioplastia con colocación de colgajo de dartos dorsal, mientras que el grupo B incluyó a los pacientes sometidos a reparación utilizando colgajo de dartos dorsal. Adicionalmente, el grupo A se dividió en dos subgrupos según el tipo de sonda utilizada (sonda vesical o sonda uretral corta).Resultados: Un total de 473 pacientes participaron en este estudio. No se observaron diferencias estadísticamente significativas en las tasas de complicaciones entre los dos grupos. En el grupo A se utilizó una sonda vesical en 107 pacientes y una sonda uretral corta en 135 pacientes. No se observaron diferencias estadísticamente significativas al comparar los resultados de los dos grupos.Conclusiones: La espongioplastia puede combinarse con la colocación de colgajo de dartos dorsal para reducir la necesidad de plicaturas dorsales, además de reducir la tasa de fístulas. Las sondas uretrales cortas pueden utilizarse de forma segura y sin efectos durante el postoperatorio en niños con control de esfínteres Objetivo Hemos empleado previamente la técnica de reparación mediante tubularización e incisión de la placa uretral (TIP) con algunas modificaciones en casos de hipospadias distal debido a sus excelentes resultados cosméticos. En este estudio se evaluaron los efectos de la espongioplastia y los colgajos de dartos dorsal y de las sondas uretrales cortas en los resultados de la reparación con TIP

Aim: We have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair.Materials and methods: Only distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent).Results: A total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference.Conclusions: Spongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training (AU)

Sondas de gastrostomía en pacientes con esclerosis lateral amiotrófica: indicaciones, seguridad y experiencia en un centro de tercer nivel / Gastrostomy tubes in patients with amyotrophic lateral sclerosis: indications, safety and experience in a tertiary care centre

Objetivo: El objetivo es la caracterización clínica de los pacientes diagnosticados de esclerosis lateral amiotrófica (ELA) a los que se les indicó la colocación de una sonda de gastrostomía (SG) en el período 2007-2017 en el Complejo Asistencial Universitario de Salamanca, y encontrar posibles factores pronósticos asociados. Material y métodos. Es un estudio descriptivo de casos clínicos. Resultados: Entre 2007 y 2017 se evaluaron 139 ELA y se indicó SG en 29 casos. De esos 29, en dos ocasiones no se llevó a cabo, en una ocasión por negativa del paciente y en otra por deterioro clínico. Del total de SG, 21 se colocaron por endoscopia; cuatro, por radiología intervencionista; y dos, por cirugía. Las principales indicaciones fueron: en 10 casos, por disfagia grave; en ocho, por pérdida ponderal > 10%; y en nueve, por disminución de la capacidad vital forzada < 50%. Entre las complicaciones inmediatas (primeras 24 horas) se observaron: dos desaturaciones intraprocedimiento, una infección de la ostomía, un dolor abdominal, un íleo paralítico y una insuficiencia respiratoria con fallecimiento. Entre las complicaciones tardías (primer mes): una neumonía, una isquemia intestinal, una celulitis y un mal control de las secreciones. La principal causa de fallecimiento fue la insuficiencia respiratoria. La mediana de tiempo desde la colocación de la SG hasta el fallecimiento fue de 7,89 meses. Se constató mejoría de los parámetros analíticos nutricionales, sin demostrarse significación estadística, como factor pronóstico. Conclusión: La colocación de una SG es un procedimiento eficaz y seguro para asegurar la nutrición enteral en los pacientes con ELA.(AU)

Aim: The aim of this study is the clinical characterisation of patients diagnosed with amyotrophic lateral sclerosis (ALS), who were indicated for the placement of a gastrostomy tube (G-Tube) in the period 2007-2017 in the Complejo Asistencial Universitario de Salamanca, and to find possible associated prognostic factors. Material and methods: It is a descriptive study of clinical cases. Results: Between 2007 and 2017, 139 cases of ALS were assessed and a G-Tube was indicated in 29 of them. Of these 29, on two occasions it was not performed, one due to the patient refusing and the other because of clinical deterioration. Of the total number of G-Tubes, 21 were placed by endoscopy, four by interventional radiology and two by surgery. The main indications were: in 10 cases, for severe dysphagia; in eight cases, for weight loss >10%; and in nine cases, for reduced forced vital capacity <50%. Immediate complications (first 24 hours) included: two intraprocedural desaturations, one ostomy infection, one abdominal pain, one paralytic ileus and one respiratory failure resulting in death. Late complications (first month) include pneumonia, intestinal ischaemia, cellulitis and poor control of secretions. The main cause of death was respiratory failure. The median time elapsed between G-Tube placement and death was 7.89 months. An improvement in analytical nutritional parameters was observed, without showing statistical significance, as a prognostic factor. Conclusion: G-Tube placement is an effective and safe procedure to ensure enteral nutrition in ALS patients.(AU)

Tubularized incised plate repair in 473 primary distal hypospadias cases: An evaluation of outcomes according to coverages and stent types.

AIM: We have previously employed the tubularized incised plate (TIP) repair technique in distal hypospadias cases with a few modifications because of its excellent cosmetic results. In this study, we aimed to evaluate the effects of spongioplasty and dorsal dartos flaps, in addition to short urethral stents on the outcomes of TIP repair. MATERIALS AND METHODS: Only distal hypospadias cases were involved in this study. Eligible patients were divided into two groups: group A included patients repaired with both spongioplasty and dorsal dartos flap placement, while group B included patients repaired with dorsal dartos flap placement alone. Group A was further divided into two subgroups according to the type of catheter used (bladder catheter or short urethral stent). RESULTS: A total of 473 patients were included in this study. There was no statistically significant difference observed in the complication rates between the two groups. In Group A, a bladder catheter was used in 107 patients and a short urethral stent was used in 135 patients. When the results of the two groups were compared, there was no statistically significant difference. CONCLUSIONS: Spongioplasty could be combined with dorsal dartos flap placement to reduce the need for dorsal plication rather than to reduce the fistula rate. Short urethral stents can be used safely with no postoperative effects in children who have completed toilet training.

mpacto de um programa de melhoria da qualidade nos erros de preparo e administração de medicamentos orais via sonda nasoenteral: estudo de intervenção / Impact of a quilite improvement program on errors in the preparation and administration of oral drugs via nasoenteral probe: intervention study

Objetivo: A presente tese é apresentada em forma de quatro artigos que se articulam por meio do objetivo geral: Avaliar o impacto de um programa de melhoria da qualidade nos erros de preparo e administração de medicamentos via sonda nasoenteral. Os objetivos específicos dos artigos foram: (artigo 1) Desenvolver um guia de boas práticas voltado para o preparo e para a administração de medicamentos orais via sonda nasoenteral, a fim de apoiar prescritores e enfermeiros na prestação de cuidados de qualidade e seguros aos pacientes hospitalizados; (artigo 2) Avaliar um programa de melhoria da qualidade para reduzir a proporção de erros no preparo e na administração de medicamentos via sonda nasoenteral; (artigo 3) avaliar a implementação de uma tomada de decisão multicritério em grupo associado a um ciclo Plan-Do-Study-Act (PDSA) dentro de um programa de qualidade para a segurança no uso de medicamentos por toda a equipe de enfermagem para o preparo dos comprimidos (trituração e reconstituição do pó) e do equipamento a ser utilizado para a lavagem da sonda durante a administração de medicamento enteral, dentro de um ciclo PDSA; (artigo 4) Avaliar o impacto de um programa de melhoria da qualidade na redução das frequências de obstruções, analisar as variáveis preditoras deste incidente de segurança e a estimativa econômica dos custos relacionados ao programa de melhoria da qualidade no período de 2014-2019. Métodos: No artigo 1, foi realizado estudo descritivo, em duas fases. Na primeira, foi realizada revisão integrativa da literatura nas bases de dados: LILACS, MEDLINE, Web of Science, MICROMEDEX® Solutions, além de busca manual no site da Agência Nacional de Vigilância Sanitária (ANVISA), em guidelines, livros texto relacionados ao assunto, teses e dissertações. Na segunda fase, o guia foi refinado para uso no hospital por meio de reuniões com a equipe multidisciplinar. No artigo 2, foi realizado estudo de intervenção voltado para a comparação de medidas de resultados antes (linha de base) e depois da implementação do programa de melhoria da qualidade voltado para a redução de erros no preparo e na administração de medicamentos orais via sonda nasoenteral. Foram utilizados os ciclos PDSA para o planejamento e para a ação do programa de melhoria. As intervenções testadas incluíram: desenvolvimento e implementação de um guia de boas práticas para auxiliar a equipe de enfermagem no preparo e na administração de medicamentos orais via sonda nasoenteral; capacitação da equipe de enfermagem com relação à utilização do guia; disponibilização, para os enfermeiras e médicos, de uma lista impressa com os medicamentos orais que não podem ser triturados e administrados via sonda nasoenteral. No artigo 3, foi utilizada uma abordagem participativa, por meio da aplicação de um Modelo de Tomada de Decisão em Grupo (MTDG), como parte do ciclo PDSA, em um hospital brasileiro, para apoiar a equipe de enfermagem na tomada de decisão sobre os processos de preparo e administração de medicamentos orais via sonda. No artigo 4, foi realizado estudo de intervenção para testar o uso de um equipamento (Easy Crush®) na tritura de comprimidos até pó fino e homogêneo. Nesta fase, medidas de resultado, de processo e de equilíbrio foram selecionadas e monitoradas ao longo do tempo, por meio de cinco ciclos PDSA. O impacto do programa de melhoria da qualidade, que ocorreu entre os anos de 2014 a 2019, foi avaliado por meio de análise de regressão logística. Além disso, foi realizada estimativa dos custos do programa de melhoria de qualidade nesse mesmo período. Resultados: Artigo 1: Na fase 1, das 104 referências encontradas, sete atenderam aos critérios de inclusão propostos para o estudo e foram lidas na íntegra. Dessa revisão, resultou a primeira versão do guia de boas práticas no preparo e na administração de medicamentos orais via sonda nasoenteral. Na fase 2, foram realizadas quatro reuniões para adaptar o guia de boas práticas ao contexto do hospital. Participaram das reuniões: três enfermeiros, uma nutricionista, uma farmacêutica e dois médicos. No artigo 2, foi observada melhora nas seguintes medidas: triturou comprimido com revestimento entérico e misturou mais de um medicamento durante o preparo (de 54,9% na Fase I para 25,6% na Fase II; p 0,0010) e triturou forma farmacêutica de ação modificada ou drágea (de 32,8% na Fase I para 19% na Fase II; p 0,0010). Contudo, piora foi verificada nas seguintes medidas: não triturou comprimido até pó fino e homogêneo (de 7,4% na Fase I para 95,3% na Fase II; p 0,0010) e sondas obstruídas (de 41,8% na Fase I para 53% na Fase II; p 0,0950). No artigo 3, participaram do processo de decisão, profissionais envolvidos no preparo e na administração de medicamentos orais via sonda nasoenteral, ou seja, a equipe de enfermagem e farmacêutica. Foram realizadas duas negociações sobre as técnicas e foi discutida a necessidade de aquisição de um novo equipamento para preparar, de modo mais eficiente, os comprimidos. Ao analisar o ciclo PDSA anterior, sem qualquer participação na tomada de decisão, com o ciclo PDSA em conjunto com o método do MTDG, aumentou as chances de implementação efetiva das práticas de melhoria da qualidade, principalmente quanto à técnica de trituração de comprimidos (de 95,3% de não conformidade no ciclo PDSA sem método MTDG para 0% de não conformidade no ciclo PDSA com método MTDG). No artigo 4, foi observada melhora na medida de resultado obstrução da sonda (de 41,8% em 2014 para 53% em 2017 e para 9,6% em 2019). Nas medidas de processo, também observamos uma redução do número de medicamentos orais prescritos via sonda nasoenteral, em 24 horas, (de 4,9% em 2014 para 5,6% em 2017 para 4,5% em 2019). Em relação ao número de medicamentos orais aprazados para o mesmo horário, também verificamos uma redução (de 3,3% em 2014 para 2,3% em 2017 para 1,3% em 2019). Na medida de equilíbrio, foi identificada melhora na seguinte medida: comprometimento de aspectos biofarmacêuticos durante a tritura de medicamentos sólidos (de 11,6% em 2014 para 12,3% em 2017 e para 0% em 2019). Na análise de regressão logística, foi verificado impacto significativo do programa de melhoria da qualidade na redução de sondas obstruídas (p=0,0010). Também foi verificado impacto positivo do programa de melhoria da qualidade no custo do preparo das doses: de R$ 1.067,50 em 2014, para R$ 719,80 em 2017 e R$ 433,10 em 2019. Conclusão: Os resultados dos estudos desenvolvidos na presente tese destacam a importância de programas de melhoria da qualidade para reduzir erros relacionados aos processos de preparo e de administração de medicamentos orais via sonda nasoenteral. As mudanças testadas por meio de ciclos PDSA impactaram significativamente os processos e resultou em redução de custos para a instituição

Objective: This thesis is presented in the form of four articles that are articulated through the general objective: To evaluate the impact of a quality improvement program on the errors of preparation and administration of drugs via nasoenteral probe. The specific objectives of the articles were: (Article 1) To involve a guide of good practices aimed at the preparation and administration of oral drugs via nasoenteral probe, in order to support prescribers and nurses in providing quality and safe care to hospitalized patients; (Article 2) Evaluate a quality improvement program to reduce the proportion of errors in the preparation and administration of drugs via nasoenteral probe; (Article 3) evaluate the implementation of a multi-criteria group decision-making associated with a Plan-Do-Study-Act (PDSA) cycle within a quality program for the safety of the use of medicines by the entire nursing team for the preparation of tablets (grinding and reconstitution of powder) and the equipment to be used for washing the probe during enteral drug administration, within a PDSA cycle; (Article 4) Evaluate the impact of a quality improvement program on reducing the frequencies of obstructions, analyze the predictor variables of this safety incident and the economic estimation of costs related to the quality improvement program in the period 2014-2019. Method: In Article 1, a descriptive study was conducted in two phases. In the first, an integrative review of the literature was performed in the databases: LILACS, MEDLINE, Web of Science, MICROMEDEX® Solutions, in addition to manual search on the website of the National Health Surveillance Agency (ANVISA), in guidelines, textbooks related to the subject, theses and dissertations. In the second phase, the guide was refined for non-hospital use through meetings with the multidisciplinary team. In Article 2, an intervention study was conducted aimed at comparing measures of results before (baseline) and after the implementation of the quality improvement program aimed at reducing errors, not preparing and administering oral medications via nasoenteral probe. Foram used PDSA cycles for planning and for the action of the improvement program. The interventions tested included: development and implementation of a good practice guide to assist the nursing team in the preparation and administration of oral medications via nasoenteral probe; training of the nursing team in relation to the use of the guide; availability, for nurses and physicians, of a printed list with oral medications that cannot be crushed and administered via nasoenteral probe. In Article 3, a participatory approach was used, through the application of a Group Decision Making Model (MTDG), as part of the PDSA cycle, in a Brazilian hospital, to support the nursing team in decision-making on the processes of preparation and administration of oral drugs via probe. In article 4, an intervention study was carried out to test the use of an equipment (Easy Crush®) in the grinding of tablets to fine and homogeneous powder. In this phase, results, process and equilibrium were selected and monitored over time, through five PDSA cycles. The impacto of the quality improvement program, which occurred between 2014 and 2019, was evaluated by logistic regression analysis. In addition, the costs of the quality improvement program were estimated in the same period. Results: Article 1: In phase 1, in the 104 references found, seven met the inclusion criteria proposed for the study and were read in full. This review resulted in the first version of the guide of good practices in the preparation and administration of oral drugs via nasoenteral tube. In phase 2, four meetings were held to adapt the guide of good practices to the hospital context. Three nurses, one nutritionist, one pharmacist and two physicians participated in the meetings. In Article 2, improvement was observed in the following measures: triturou tablet with enteric coating and mixed more than one drug during preparation (from 54.9% in Phase I to 25.6% in Phase II; p 0.0010) and crushed pharmaceutical form of modified or drágea action (from 32.8% in Phase I to 19% in Phase II; p 0.0010). However, worsening was observed in the following measures: it did not grind tablet to fine and homogeneous powder (from 7.4% in Phase I to 95.3% in Phase II; p 0.0010) and obstructed probes (from 41.8% in Phase I to 53% in Phase II; p 0.0950). In Article 3, professionals involved in the preparation and administration of oral medications via nasoenteral probe, i.e., the nursing and pharmaceutical team, were based in the decision-making process. Two negotiations were held on the techniques and the need to purchase new equipment was discussed to prepare the tablets more efficiently. By analyzing the previous PDSA cycle, without any participation in decision making, with the PDSA cycle in conjunction with the MTDG method, the chances of effective implementation of quality improvement practices increased, especially regarding the tablet crushing technique (95.3% non-conformity in the PDSA cycle without PARA MTDG method 0% non-conformity in the PDSA cycle with MTDG method). In Article 4, an improvement was observed in the measurement of probe obstruction result (from 41.8% in 2014 to 53% in 2017 and to 9.6% in 2019). In the process measures, we also observed a reduction in the number of oral drugs prescribed via nasoenteral tube in 24 hours (from 4.9% in 2014 to 5.6% in 2017 to 4.5% in 2019). Regarding the number of oral medicines available for the same time, we also found a reduction (from 3.3% in 2014 to 2.3% in 2017 to 1.3% in 2019). In the equilibrium measure, improvement was identified in the following measure: impairment of biopharmaceutical aspects during the crushing of solid drugs (from 11.6% in 2014 to 12.3% in 2017 and to 0% in 2019). In the logistic regression analysis, a significant impact of the quality improvement program on the reduction of obstructed probes was verified (p=0.0010). It was also verified a positive impact of the program to improve the quality of the cost of preparing doses: from R$ 1,067.50 in 2014, to R$ 719.80 in 2017 and R$ 433.10 in 2019. Conclusion: The results of the studies developed in this thesis highlight the importance of quality improvement programs to reduce errors related to the processes of preparation and administration of oral drugs via nasoenteral probe. The changes tested through PDSA cycles significantly impacted the processes and resulted in cost reduction for the institution

Resultados a medio plazo de la uretroplastia distal con colocación de sonda y sin ella. Análisis retrospectivo sobre la necesidad de reintervención y los resultados estéticos / Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results

Introducción: La tasa de complicaciones a largo plazo tras la reparación del hipospadias distal puede ascender al 20%, y aún no disponemos de directrices sobre la colocación de la sonda en la uretroplastia distal. Hemos analizado de forma retrospectiva la tasa de reintervención de la uretroplastia a medio plazo y los resultados estéticos tras un estudio piloto de 2años sobre las uretroplastias distales con colocación de sonda o sin ella.Materiales y métodosUn cirujano pediátrico realizó 11 procedimientos con la técnica de Snodgrass con colocación de sonda (grupo A) y 17 sin colocación de sonda (grupo B) en nuestra institución (2011-2013). La mediana de edad de los pacientes en la cirugía fue de 2,1 años (rango 1-8,5).Los criterios de inclusión fueron: defecto distal primitivo, un único cirujano en ambos procedimientos y alta sin sonda.La mediana de seguimiento fue de 6,4 años (rango 1,5-8,1).Los resultados clínicos y estéticos postoperatorios fueron evaluados al menos una vez mediante la herramienta HOSE (Hypospadias Objective Scoring Evaluation).El objetivo de nuestro estudio fue comparar las complicaciones y las tasas de repetición de la uretroplastia a medio plazo antes de iniciar un estudio aleatorizado. Se hizo un análisis retrospectivo. Se utilizó la prueba exacta de Fisher (p <0,05) para el análisis estadístico.ResultadosDe los 28 del total, 5 complicaciones requirieron una segunda cirugía: 2/11 casos con sonda, 3/17 sin sonda. Los resultados estéticos fueron satisfactorios en ambos grupos. Los resultados no alcanzaron significación estadística (p=1.000). (AU)

Introduction: Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need of a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-year pilot study on stented/un-stented distal urethroplasties.Materials and methodsA total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by one pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5).Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge.The median follow-up was 6.4 years (range 1.5-8.1).All patients received at least one post-operative clinical-cosmetic examination (HOSE).The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P<0.05) for statistical analysis.ResultsOf 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P=1.000). (AU)

Medium-term outcome after stented and un-stented distal urethroplasty: A retrospective analysis on redo-urethroplasty need and cosmetic results.

INTRODUCTION: Long-term complication rates after distal hypospadias repair can be close to 20%. There are no available guidelines regarding the need for a catheter in distal urethroplasty. We report a retrospective analysis on medium-term redo-urethroplasty rate and cosmetic results after a two-years pilot study on stented/un-stented distal urethroplasties. MATERIALS AND METHODS: A total of 11 stented (Group A) and 17 un-stented (Group B) Snodgrass-procedures were performed by the same pediatric surgeon at our Institution (2011-2013). The median age at surgery was 2.1 years (range 1-8.5). Inclusion criteria were primitive distal defect, same surgeon in both interventions, catheter-free discharge. The median follow-up was 6.4 years (range 1.5-8.1). All patients received at least one post-operative clinical-cosmetic examination (HOSE). The aim of our study was to compare medium-term complications and redo-urethroplasty rates before starting a randomized study. A retrospective analysis was performed. We used Fisher's exact-test (P < 0.05) for statistical analysis. RESULTS: Of 28 complications, 5 required redo-surgery: 2/11 stented-cases, 3/17 un-stented. Cosmetic results were satisfactory in both groups. These results were not statistically significant (P = 1.000). CONCLUSION: Long-term follow-up is mandatory to know redo-urethroplasty rate and cosmetic outcome after distal stented/un-stented repair. Further studies are needed to evaluate the role of catheter placement and the definitive outcome in distal urethroplasty.