Mejorando la cadena de suministro en un hospital mediante la gestión Lean / Improving a hospital's supply chain through lean management

Objetivos. La gestión del suministro constituye un área en la que los hospitales tienen importantes oportunidades de mejora. Este trabajo pretende analizar cómo la aplicación de los principios de Lean puede mejorar los costes logísticos y la satisfacción de los usuarios. Métodos. Análisis de los resultados de una experiencia de reorganización del sistema logístico de un hospital basada en algunos principios Lean. Para el cálculo de los costes logísticos se ha utilizado el método del coste completo o full costing de contabilidad analítica de gestión. La satisfacción del usuario se evaluó mediante encuesta anónima. El tratamiento de los datos de la encuesta incluyó análisis factorial y el modelo de análisis de la varianza ANOVA. Resultados. Los datos obtenidos mostraron una mejora en la gestión de logística tras la implantación de Lean, con reducción de costes y mejora del nivel de satisfacción del usuario interno. Se ha observado que el personal sanitario percibe y valora el servicio logístico de manera global, sin diferenciar los aspectos del servicio, detectándose diferencias en cuanto al grado de satisfacción percibida por distintos grupos de usuarios. Conclusiones. La experiencia analizada ha permitido comprobar la aplicabilidad e idoneidad de los principios Lean para mejorar los costes e incrementar la satisfacción de los usuarios de servicios logísticos hospitalarios (AU)

Objectives: Supply management is an area where hospitals have significant opportunities for improvement. The main objective of this paper has been to analyze how the application of Lean principles can improve logistics costs and user satisfaction. In connection with satisfaction, it also aimed to examine which aspects of the service define it and check for differences between different groups of users. Methods: The results of an experience to reorganize the hospital logistic system based on some Lean principles have been studied. This is therefore a case study, which combine different methods of data collection. The logistics cost calculation was carried out using the full costing method. To measure satisfaction of healthcare personnel, the internal logistics service users, an anonymous survey was conducted. Processing of the data obtained from the survey have included exploratory analysis, factor analysis and ANOVAs. Results: The data have showed an improvement in logistics management after the implementation of Lean principles. Logistics costs were reduced and the satisfaction level of the internal users with the new logistics system was increased. Some differences in the degree of satisfaction by different groups of users were also detected, although they did not seem to distinguish between different aspects of logistic service. Conclusions: The analyzed experience shows the applicability and suitability of Lean principles to improve logistics operational costs and increase user satisfaction (AU)

[Improving a hospital's supply chain through lean management]. / Mejorando la cadena de suministro en un hospital mediante la gestión Lean.

OBJECTIVES: Supply management is an area where hospitals have significant opportunities for improvement. The main objective of this paper has been to analyze how the application of Lean principles can improve logistics costs and user satisfaction. In connection with satisfaction, it also aimed to examine which aspects of the service define it and check for differences between different groups of users. METHODS: The results of an experience to reorganize the hospital logistic system based on some Lean principles have been studied. This is therefore a case study, which combine different methods of data collection. The logistics cost calculation was carried out using the full costing method. To measure satisfaction of healthcare personnel, the internal logistics service users, an anonymous survey was conducted. Processing of the data obtained from the survey have included exploratory analysis, factor analysis and ANOVAs. RESULTS: The data have showed an improvement in logistics management after the implementation of Lean principles. Logistics costs were reduced and the satisfaction level of the internal users with the new logistics system was increased. Some differences in the degree of satisfaction by different groups of users were also detected, although they did not seem to distinguish between different aspects of logistic service. CONCLUSIONS: The analyzed experience shows the applicability and suitability of Lean principles to improve logistics operational costs and increase user satisfaction.

Strong association of socioeconomic status with genetic ancestry in Latinos: implications for admixture studies of type 2 diabetes.

AIMS/HYPOTHESIS: Type 2 diabetes is more prevalent in US American minority populations of African or Native American descent than it is in European Americans. However, the proportion of this epidemiological difference that can be ascribed to genetic or environmental factors is unknown. To determine whether genetic ancestry is correlated with diabetes risk in Latinos, we estimated the proportion of European ancestry in case-control samples from Mexico and Colombia in whom socioeconomic status had been carefully ascertained. METHODS: We genotyped 67 ancestry-informative markers in 499 participants with type 2 diabetes and 197 controls from Medellín (Colombia), as well as in 163 participants with type 2 diabetes and 72 controls from central Mexico. Each participant was assigned a socioeconomic status scale via various measures. RESULTS: Although European ancestry was associated with lower diabetes risk in Mexicans (OR [95% CI] 0.06 [0.02-0.21], p = 2.0 x 10(-5)) and Colombians (OR 0.26 [0.08-0.78], p = 0.02), adjustment for socioeconomic status eliminated the association in the Colombian sample (OR 0.64 [0.19-2.12], p = 0.46) and significantly attenuated it in the Mexican sample (OR 0.17 [0.04-0.71], p = 0.02). Adjustment for BMI did not change the results. CONCLUSIONS/INTERPRETATION: The proportion of non-European ancestry is associated with both type 2 diabetes and lower socioeconomic status in admixed Latino populations from North and South America. We conclude that ancestry-directed search for genetic markers associated with type 2 diabetes in Latinos may benefit from information involving social factors, as these factors have a quantitatively important effect on type 2 diabetes risk relative to ancestry effects.

The role of destabilization of palladium hydride in the hydrogen uptake of Pd-containing activated carbons.

This paper reports on differences in stability of Pd hydride phases in palladium particles with various degrees of contact with microporous carbon supports. A sample containing Pd embedded in activated carbon fibre (2 wt% Pd) was compared with commercial Pd nanoparticles deposited on microporous activated carbon (3 wt% Pd) and with support-free nanocrystalline palladium. The morphology of the materials was characterized by electron microscopy, and the phase transformations were analysed over a large range of hydrogen partial pressures (0.003-10 bar) and at several temperatures using in situ x-ray diffraction. The results were verified with volumetric hydrogen uptake measurements. Results indicate that higher degrees of Pd-carbon contacts for Pd particles embedded in a microporous carbon matrix induce efficient 'pumping' of hydrogen out of beta- PdHx. It was also found that thermal cleaning of carbon surface groups prior to exposure to hydrogen further enhances the hydrogen pumping power of the microporous carbon support. In brief, this study highlights that the stability of beta- PdHx phase supported on carbon depends on the degree of contact between Pd and carbon and on the nature of the carbon surface.

Fracaso renal agudo en el paciente pediátrico / Acute renal failure in pediatric patients

El FRA en los niños puede ser definido como un brusco descenso de la función renal o bien, un incremento de la creatinina sérica por encima de dos veces los valores normales para su edad y sexo y siempre que el incremento sea superior a 1 mg/dl en pacientes con función renal previa normal. La mayoría de los pacientes tiene oliguria, que se considera cuando la diuresis es menor de 0.5 ml/Kg/h durante más de 4 horas, resistente a la replección de volumen, la dopamina o furosemida. Los episodios de FRA son frecuentemente divididos en prerenales y renales. Los primeros cuando la historia clínica y la situación sugiera una hipoperfusión renal y a la que se añade una excreción fraccional de sodio inferior a 1 si el niño tiene más de 1 mes, o inferior a 2.5 si es menor de 1 mes. El FRA es poco frecuente en niños y esta incidencia es difícil de definir. En un estudio prospectivo, multicéntrico realizado en Madrid esta resultó 2,7 casos por millón de habitantes y año. Los casos de FRA varían con la edad y las malformaciones y son más frecientes en los más jóvenes. El pronóstico de estos pacientes no es bueno y la mortalidad varía con la causa desencadenante, la situación clínica del paciente, así como del número y características de las complicaciones. Los indicadores de mortalidad usados en las unidades de cuidados intensivos son habitualmente usados para predecir la evolución. Sin embargo el pronostico de los niños es mejor que el de los adultos (25% vs 50%), pero los estudios son difíciles de comparar pues existen diferencias de edad concreta, o son diferentes las etiologías o son diferentes las definiciones que se proponen para FRA. Como se han diseñado equipos específicos para niños, todos los medios de diálisis pueden ser usados en el paciente pediátrico. La diálisis peritoneal fue la forma preferida, pero el uso de las técnicas extracorpóreas está creciendo y la elección de la técnica de diálisis depende de las circunstancias clínicas y la experiencia del personal. La diálisis peritoneal es una técnica continua que no requiere ni anticoagulación, ni acceso vascular y puede ser usada si existe inestabilidad hemodinámica en cualquier edad incluidos neonatos. Para niños más estables con FRA el uso de hemodiálisis intermitente es la mejor elección. La hemofiltración es más efectiva que la peritoneal y es preferible en aquellos pacientes que están inestables hemodinámicamente o en los que se pretende una extracción continua del volumen extracelular o de toxinas. El propósito de este capítulo es dar información práctica en el tratamiento conservador del FRA y analiza las ventajas y desventajas de las diferentes técnicas de diálisis

Acute Renal Failure (ARF) in childhood can be defined as a sudden decrease of renal function enough to increase serum creatinine (SCr) more than two fold normal value for age and sex matched controls and always above 1 mg/dl, in patients with previously normal renal function. Most patients have oliguria, which is considered as an urine output less than 0.5 ml/Kg/h. for more than 4 hours, resistant to volume repletion, dopamine and/or furosemide. Episodes of ARF are usually divided into pre-renal and renal. The former are those whose clinical history and situation suggest renal hypoperfusion and, in addition, they have a Renal Failure Index and Fractional Excretion of Na <1 if aged over one month and < 2.5 below this age. ARF is uncommon in childhood and its incidence is hard to define, in a prospective and multicentre study performed in Madrid, it was 2.7 cases per million inhabitants per year The causes of ARF vary with age and malformative disorders are more frequent in younger children. The outcome of patients is severe and mortality is related to the underlying disease, the clinical situation of the patient, as well as the number and characteristics of the complications. The mortality scores used in Intensive Care Units are usually applied to predict the evolution. It is widely accepted that prognosis in childhood is better than in adults (25% vs 50%), but the studies are difficult to compare because they deal with specific age or etiologic groups or are based on different definitions of ARF. As availability of equipment designed for children has increased, all means of dialytic support can be applied to the pediatric patient. Peritoneal dialysis was previously the preferred therapy but extracorporeal techniques are being increasingly used and the choice of dialysis therapy depends on the clinical circumstances and expertise available Peritoneal dialysis is a continuous therapy that requires neither anticoagulation nor vascular access and can be used in hemodynamically unstable patients of all ages, including neonates For more stable children with ARF intermittent acute hemodialysis remains the best choice. Hemofiltration is more effective than peritoneal dialysis and is usually preferred in patients who are hemodynamically unstable or where continuous removal of extracellular volume or toxins is desired. The goal of this chapter is to provide practical information of the conservative ARF management and advantages and disadvantages of available dialysis modalities

[Chronic renal failure secondary to hyperoxaluria following small bowel syndrome]. / Insuficiencia renal crónica secundaria a hiperoxaluria tras resección intestinal por trombosis mesentérica.

A 70-year-old woman was admitted in the Department of Nephrology because of renal insufficiency. Six years previously, as consequence of a venous mesenteric thrombosis, she underwent an extense intestinal resection with subsequent short intestine syndrome. Five years after the surgery an increase in the creatinine concentration was observed (1.4 mg/dl). One year later, it increased up to 3.1 mg/dl and the patient was remitted to our Department. The radiological study revealed calcifications on both kidney silhouettes. In the next year, renal function worsened and the calcifications increased. Coinciding with the beginning of the chronic hemodialysis treatment she suffered a renal colic with passage of a calcium oxalate stone.

Insuficiencia renal crónica secundaria a hiperoxaluria tras resección intestinal por trombosis mesentérica / Chronic renal failure secondary to hyperoxaluria following small bowel syndrome

Una enferma de 70 años de edad fue remitida al Servicio de Nefrología por insuficienciarenal (concentración de creatinina en plasma: 3,1 mg/dl). Seis añosantes había sido intervenida quirúrgicamente por abdomen agudo secundario atrombosis venosa mesentérica, y se le realizó una resección intestinal amplia conanastomosis entre yeyuno e íleon distal. A partir de la cirugía la enferma presentóun síndrome de intestino corto con estatorrea. La concentración plasmática decreatinina se mantuvo en el rango normal hasta el quinto año postoperatorio enque se detectó una cifra de 1,4 mg/dl. Al año siguiente la concentración de creatininaera de 3,1 mg/dl y la enferma fue enviada al Servicio de Nefrología. En elestudio inicial se comprobó la existencia de calcificaciones sobre ambas siluetasrenales sin objetivarse dilatación de la vía urinaria. La función renal se deterioróprogresivamente y un año más tarde (7 años después de la cirugía) comenzó tratamientocon hemodiálisis periódica. En ese momento se constató un aumento delas calcificaciones renales con nefrocalcinosis bilateral. Coincidiendo con el iniciodel tratamiento con hemodiálisis, la enferma tuvo un cólico renal expulsando uncálculo de oxalato cálcico

A 70 years old woman was admitted in the Department of Nephrology becauseof renal insufficiency. Six years previously, as consequence of a venous mesentericthrombosis, she underwent an extense intestinal resection with subsequent short intestinesyndrome. Five years after the surgery an increase in the creatinine concentrationwas observed (1.4 mg/dl). One year later, it increased up to 3.1 mg/dl andthe patient was remitted to our Department. The radiological study revealed calcifications on both kidney silhouettes. In the next year, renal function worsened andthe calcifications increased. Coinciding with the beginning of the chronic hemodialysistreatment she suffered a renal colic with passage of a calcium oxalate stone

Nefrología basada en investigación clínica: bases conceptuales para la constitución de un grupo de trabajo en Nefrología Basada en la Evidencia de la Sociedad Española de Nefrología / No disponible

No disponible

[Long-term prognosis of childhood IgA nephropathy in adult life]. / Pronóstico en la vida adulta de la nefropatía IgA diagnosticada en la edad pediátrica.

BACKGROUND: To evaluate long-term prognosis in a group of children with IgA nephropathy and to analyse which clinical factors were associated with progression to chronic renal failure in adulthood. PATIENTS AND METHOD: Retrospective study. 58 young adults with IgA nephropathy diagnosed at 10.6(SD 2.9) years old and studied after a follow-up of 11.8 (SD 2.9) years. RESULTS: Relapses of macroscopic hematuria and proteinuria were the most frequent symptoms at onset (75.9%). In 25.9% of patients high plasmatic IgA levels were also detected. Most cases had grade I (44.8%)or grade II (44.8%) histological lesions at diagnosis. At the last control, clinical remision was observed in 21 patients (36.2%) and 50% of the whole group remained with abnormal urine. 8 patients(13.8%) reached terminal renal failure. Mean renal survival (defined as glomerular filtration rate above 50 ml/min/1.73 m2)was 100, 93.3 and 81.1% at 5, 10 and 15 years of evolution, respectively. CONCLUSIONS: About 14% of children with IgA nephropathy had long-term renal bad prognosis. Hypertension at onset, plasma creatinine elevation and proteinuria during adolescence were significant risk factors associated with chronic renal failure during adulthood. Minimal lesions at IgA nephropathy diagnosis in children did not exclude long-term poor prognosis.

Prognosis of patients with acute renal failure without cardiopathy.

BACKGROUND: The outcome for children with acute renal failure (ARF) may be poor. However, relatively few published studies have considered prognosis of these patients. METHODS: We prospectively studied, from 1978 to 1998, 92 such children without heart disease to try to identify risk factors for mortality. RESULTS: Forty five per cent of children with tumours, shock, and other causes died compared with none of those with a primary urinary tract related problem. ARF did not seem to be the cause of death in any case. Univariate analysis showed that in the non-primary urinary problem group (55 cases), patients with hypotension, high values of BUN or creatinine, or who needed mechanical ventilation or dialysis, had a poor outcome. Multivariate analysis showed that probability of death can be estimated using the following score: -0.02 + 0.28 (hypotension) + 0.19 (ventilation) + 0.27 (dialysis) + 0.01 (BUN). CONCLUSIONS: Mortality of patients with ARF was related to aetiology, the need for dialysis and/or ventilator use, hypotension, and BUN values.

Renovascular hypertension in children.

OBJECTIVE: To study the etiology, clinical spectrum. image findings, management and outcome of children with renovascular hypertension (RVH). MATERIAL AND METHODS: Twenty children (aged 5 days to 15 years) were studied and treated for RVH during 1977-1998. In 14 cases hypertension was found during a routine examination. Six cases had heart failure and/or hypertensive encephalopathy. Diagnosis was made with aortography. Post-captopril renography and Doppler ultrasonography were obtained in 8 patients and spiral computed tomography angiography in 2. Treatment consisted of surgery (8 patients), percutaneous transluminal angioplasty (PTA) (5) or antihypertensive drugs only (8). RESULTS: Initial blood pressure was 62 +/- 31 mmHg > 95th percentile for systolic and 44 +/- 22 mmHg for diastolic blood pressure. Twelve children had unilateral and 8 had bilateral arterial stenosis. In 3 cases lesions were intrarenal. RVH was due to fibromuscular dysplasia (7 patients) and associated to middle aortic syndrome (5). neurofibromatosis (3), William's syndrome (2). Takayasu's arteritis (1) and pheochromocytoma (1). Treatment of choice was decided depending on the size of the child and location and severity of the stenosis. At the end of the follow-up (78 +/- 49 months), 9 patients are normotensive without medication and 7 are normotensive with drugs. Three patients have died, 2 for unrelated causes and I for cardiac failure; 1 child was lost to the follow-up. CONCLUSIONS: Although symptoms are relatively uncommon. renovascular disease is a frequent cause of severe hypertension in childhood. Non-invasive diagnostic techniques appear useful as screening methods. Treatment by surgery or PTA is successful if patients are carefully selected.

Tubulointerstitial nephritis and asymptomatic uveitis.

We describe a case of a 10 year-old boy who had fever, weakness, anorexia, weight loss and general malaise. No other remarkable symptoms were present. He had been treated with Aspirin and Ibuprofen. Deterioration of renal function, glucosuria, proteinuria, anemia and increased erythrocyte sedimentation rate were detected. After 7 days observation with no treatment, renal function worsened, glucosuria increased and fever persisted. A renal biopsy was performed and acute tubulointerstitial nephritis was diagnosed. The most common aetiologies of this entity were excluded. An ophthalmologic study revealed bilateral anterior uveitis, therefore the patient was diagnosed as having tubulointerstitial nephritis with uveitis. The child improved on corticosteroid therapy, but uveitis relapsed when treatment was stopped.

[Recurrence and prognostic factors after treatment with antithyroid agents in Graves-Basedow disease. Multicenter study in Northern Spain]. / Recidiva y factores pronósticos tras tratamiento con antitiroideos en la enfermedad de Graves-Basedow. Estudio multicéntrico en el norte de España.

Therapy with anti-thyroid drugs is the initial option mostly used in our country for the treatment of hyperthyroidism due to Graves-Basedow disease. To evaluate the long term results of this kind of therapy, a total of 773 patients were studied who were diagnosed from 1975 to 1994 in three hospitals in Northern Spain (Hospital Central de Asturias, Hospital de Cruces and Hospital de Navarra) after a mean follow-up time after anti-thyroid drug withdrawal of 46 +/- 33.1 months. The results showed a likelihood of hyperthyroidism relapse of 42.9%, 59.8%, 67.9% and 78.9% at one, three, five and ten years, respectively. Goitre size was correlated very significantly with the likelihood of relapse (p < 0.0001). In contrast, only TBII positivity at the end of therapy among the remaining parameters (age, sex, goitre size, length of therapy, positivity of anti-thyroid antibodies and TBII) influenced significantly on the relapse likelihood (p < 0.05). In conclusion, after a long term follow-up after anti-thyroid therapy, a high relapse rate of hyperthyroidism in Graves-Basedow disease, which amounts up to 79% at ten years, was observed. Goitre size was the main predictive factor for this relapse.

Recidiva y factores pronósticos tras tratamiento con antitiroideos en la enfermedad de Graves-Basedow. Estudio multicéntrico en el norte de España / Relapse and prognostic factors after anti-thyroid therapy for Graves-Basedow disease. Multicentric study in Northern Spain

Recidiva y factores pronósticos tras tratamiento con antitiroideos en la enfermedad de Graves-Basedow. Estudio multicéntrico en el norte de España El tratamiento con fármacos antitiroideos es la opción inicial más utilizada en nuestro país para el tratamiento del hipertiroidismo por enfermedad de Graves-Basedow. Para evaluar el resultado a largo plazo de este tipo de tratamiento hemos estudiado 773 pacientes diagnosticados entre 1975 y 1994 en tres hospitales del norte de España (Hospital Central de Asturias, Hospital de Cruces y Hospital de Navarra) después de un tiempo medio de seguimiento tras la retirada de los antitiroideos de 46 ñ 33,1 meses. Los resultados mostraron una probabilidad de recidiva del hipertiroidismo del 42,9 por ciento al año, del 59,8 por ciento a los 3 años, del 67,9 por ciento a los 5 años y del 78,9 por ciento a los 10 años. El tamaño del bocio se correlacionó muy significativamente con la probabilidad de recidiva (p < 0,0001), mientras que del resto de las variables estudiadas (edad, sexo, tamaño del bocio, duración del tratamiento, positividad de los anticuerpos antitiroideos y de los TBII) sólo la positividad de los TBII al final del tratamiento influyó de forma muy significativa (p < 0,05). En conclusión, tras un seguimiento a largo plazo después del tratamiento con antitiroideos se observa una alta tasa de recidiva del hipertiroidismo en la enfermedad de Graves-Basedow, que llega a ser del 79 por ciento a los 10 años, siendo el tamaño del bocio el factor fundamental a la hora de predecir esta recidiva (AU)