Acute Horner syndrome secondary to glandular fever due to Epstein Barr virus infection.

We present a clinical situation where a 47-year old female patient consulted with left partial ptosis and miosis that started, two weeks before, with an episode of glandular fever secondary to Epstein-Barr infection. Apraclonidine 0.5% and Phenylephrine 1% drop testing was performed with results consistent with suspected left Horner Syndrome (HS), with a probable postganglionic location. Magnetic Resonance Angiography (MRA) at the moment of the acute presentation did not show any image suggesting carotid arterial dissection but showed irregular narrowing of the left internal carotid artery on its paravertebral extracranial way, consistent to enlarged intra-carotid sheath lymphoid tissue. A week later, a Doppler ultrasound was performed, showing bilateral images compatible with internal carotid arterial dissection. When Postganglionar HS is suspected, the first aetiology to rule out is a carotid arterial dissection because of its potentially fatal outcome and for being a more described entity as postganglionic HS aetiology. However, it is also evidenced that a certain diagnose is not always possible. Furthermore, we describe the enlarged internal carotid artery sheath lymphoid tissue as a possible cause of sympathetic nerve disruption causing a Postganglionar HS, although not common.

Síndrome de Horner agudo secundario a mononucleosis infecciosa por virus de Epstein Barr / Acute Horner syndrome secondary to glandular fever due to Epstein Barr virus infection

Presentamos el caso clínico de una mujer de 47 años que consultó por miosis y ptosis del ojo izquierdo cuyo inicio coincidió, 15 días antes, con un episodio de mononucleosis infecciosa con serología positiva para virus de Epstein-Barr. Se realizaron test con colirios de apraclonidina al 0,5% y fenilefrina al 1%, que apoyaron el diagnóstico de síndrome de Horner(SH) izquierdo posganglionar. En el momento agudo se practicó una angiografía por resonancia magnética que descartó disección carotídea, pero evidenció una imagen de arrosariamiento de la arteria carótida interna izquierda a lo largo de su trayecto extracraneal paravertebral compatible con inflamación del tejido linfático de la capa adventicia de la arteria. Una semana más tarde la ecografía Doppler de troncos supraaórticos con la que se completó el estudio mostraba una imagen compatible con disección de la arteria carótida interna bilateral. Ante un caso de SH posganglionar la primera causa a descartar por su gravedad, y por ser una entidad más ampliamente descrita como etiología del SH de 3.ª neurona, es la disección carotídea. Sin embargo, con este caso ponemos de manifiesto que no siempre se puede llegar a un diagnóstico certero. Asimismo, describimos la inflamación del tejido linfático carotídeo como posible etiología de una lesión de la cadena simpática cervical como causa infrecuente de SH posganglionar (AU)

We present a clinical situation where a 47-year old female patient consulted with left partial ptosis and miosis that started, two weeks before, with an episode of glandular fever secondary to Epstein-Barr infection. Apraclonidine 0.5% and Phenylephrine 1% drop testing was performed with results consistent with suspected left Horner Syndrome (HS), with a probable postganglionic location. Magnetic Resonance Angiography (MRA) at the moment of the acute presentation did not show any image suggesting carotid arterial dissection but showed irregular narrowing of the left internal carotid artery on its paravertebral extracranial way, consistent to enlarged intra-carotid sheath lymphoid tissue. A week later, a Doppler ultrasound was performed, showing bilateral images compatible with internal carotid arterial dissection. When Postganglionar HS is suspected, the first aetiology to rule out is a carotid arterial dissection because of its potentially fatal outcome and for being a more described entity as postganglionic HS aetiology. However, it is also evidenced that a certain diagnose is not always possible. Furthermore, we describe the enlarged internal carotid artery sheath lymphoid tissue as a possible cause of sympathetic nerve disruption causing a Postganglionar HS, although not common (AU)

Análisis de la aceptación y validez de los métodos utilizados para la implementación de un programa de formación basado en competencias en un servicio de Medicina Intensiva de un hospital universitario de referencia / Acceptance and validity of the methods used to implement a competency based medical education programme in an Intensive Care Department of a teaching referral center

Objetivos: 1) Determinar la satisfacción de tutores y residentes con la metodología utilizada para la implementación de CoBaTrICE, y 2) determinar la validez y la fiabilidad de las escalas de valoración global diseñados ad hoc para analizar el desempeño de los residentes con fines formativos. Diseño: Estudio prospectivo de cohortes. Participantes: Todos los residentes y tutores del Servicio de Medicina Intensiva del Hospital Universitario y Politécnico La Fe de Valencia. Intervención: En marzo del 2016 se inició la implementación de CoBaTrICE sustentada en: 1) formación de los tutores en técnicas de retroalimentación; 2) realización por los residentes de múltiples ejercicios reales de evaluación objetiva y estructurada para adquirir las competencias del programa, y 3) uso de un portafolio electrónico para registrar las evidencias del progreso y estimular la reflexión. Métodos: La satisfacción con CoBaTrICE se evaluó mediante una encuesta realizada tras 9 meses de implementación a los 15 residentes y 5 tutores del servicio. Se preguntó sobre la metodología de las evaluaciones, calidad de la retroalimentación, autorregulación del aprendizaje y utilidad del portafolio. Se determinaron la consistencia interna (alfa de Cronbach), índices de generalizabilidad y fiabilidad interjueces (índice de correlación intraclase) de las escalas de valoración global. Resultados: La aplicación de CoBaTrICE fue satisfactoria en todas las dimensiones estudiadas. Se constataron la validez y la fiabilidad de las escalas de valoración utilizadas. Conclusiones: La metodología utilizada para implementar CoBaTrICE fue valorada positivamente por tutores y residentes. Las escalas de valoración global utilizadas en la evaluación formativa demostraron ser válidas, fiables y reproducibles. (AU)

Objectives; 1. To determine the satisfaction of tutors and residents with a specific methodology used to implement CoBaTrICE; 2. To determine the reliability and validity of the global rating scales designed ad hoc to assess the performance of the residents for training purposes. Design Prospective cohort study Participants All the residents and tutors of the ICU Department of the Hospital Universitario y Politécnico la Fe de Valencia. Intervention CoBaTrICE implementation started in March 2016, it was based on: 1) Training the tutors in feedback techniques; 2) Performing multiple objective and structured work based assessments to achieve the competences of the program; and 3) The use of an electronic portfolio to promote learning reflection and to collect the evidence that learning was taking place. Methods The acceptance of CoBaTrICE was explored through a satisfaction survey conducted after 9 months of implementation of the training program. The 15 residents and 5 tutors of the ICU Department were asked about the methodology of the formative assessments, the quality of the feedback, self-learning regulation and the electronic portfolio usefulness. The validity of the global rating scales was assessed through the tests alfa de Cronbach, reliability and generalizability indexes, and intraclass correlation coefficient. Results The implementation of CoBaTrICE was satisfactory in all the dimensions studied. The global rating scales used for formative purposes showed reliability and validity. Conclusions The methodology used to implement CoBaTrICE was highly valued by tutors and residents. The global rating scales used for formative purposes showed reliability and validity. (AU)

Acceptance and validity of the methods used to implement a competency based medical education programme in an Intensive Care Department of a teaching referral center.

OBJECTIVES: 1. To determine the satisfaction of tutors and residents with a specific methodology used to implement CoBaTrICE. 2. To determine the reliability and validity of the global rating scales designed ad hoc to assess the performance of the residents for training purposes. DESIGN: Prospective cohort study. PARTICIPANTS: All the residents and tutors of the ICU Department of the Hospital Universitario y Politécnico la Fe de Valencia. INTERVENTION: CoBaTrICE implementation started in March 2016, it was based on: (1) Training the tutors in feedback techniques; (2) Performing multiple objective and structured work based assessments to achieve the competences of the program; and (3) The use of an electronic portfolio to promote learning reflection and to collect the evidence that learning was taking place. METHODS: The acceptance of CoBaTrICE was explored through a satisfaction survey conducted after 9 months of implementation of the training program. The 15 residents and 5 tutors of the ICU Department were asked about the methodology of the formative assessments, the quality of the feedback, self-learning regulation and the electronic portfolio usefulness. The validity of the global rating scales was assessed through the tests alfa de Cronbach, reliability and generalizability indexes, and intraclass correlation coefficient. RESULTS: The implementation of CoBaTrICE was satisfactory in all the dimensions studied. The global rating scales used for formative purposes showed reliability and validity. CONCLUSIONS: The methodology used to implement CoBaTrICE was highly valued by tutors and residents. The global rating scales used for formative purposes showed reliability and validity.

Changes of resistance rates in Pseudomonas aeruginosa strains are unrelated to antimicrobial consumption in ICU populations with invasive device-related infection / Los cambios en la resistencia de cepas de Pseudomonas aeruginosa identificadas en infecciones relacionadas con dispositivos invasores no se relacionan con el consumo de antibióticos en la UCI

OBJECTIVE: To evaluate the relationship between antipseudomonal antibiotic consumption and each individual drug resistance rate in Pseudomonas aeruginosa strains causing ICU acquired invasive device-related infections (IDRI). DESIGN: A post hoc analysis was made of the data collected prospectively from the ENVIN-HELICS registry. SETTING: Intensive Care Units participating in the ENVIN-UCI registry between the years 2007 and 2016 (3-month registry each year). PATIENTS: Patients admitted for over 24h. MAIN VARIABLES: Annual linear and nonlinear trends of resistance rates of P. aeruginosa strains identified in IDRI and days of treatment of each antipseudomonal antibiotic family per 1000 occupied ICU bed days (DOT) were calculated. RESULTS: A total of 15,095 episodes of IDRI were diagnosed in 11,652 patients (6.2% out of a total of 187,100). Pseudomonas aeruginosa was identified in 2095 (13.6%) of 15,432 pathogens causing IDRI. Resistance increased significantly over the study period for piperacillin-tazobactam (P<0.001), imipenem (P=0.016), meropenem (P=0.004), ceftazidime (P=0.005) and cefepime (P=0.015), while variations in resistance rates for amikacin, ciprofloxacin, levofloxacin and colistin proved nonsignificant. A significant DOT decrease was observed for aminoglycosides (P<0.001), cephalosporins (P<0.001), quinolones (P<0.001) and carbapenems (P<0.001). CONCLUSIONS: No significant association was observed between consumption of each antipseudomonal antibiotic family and the respective resistance rates for P. aeruginosa strains identified in IDRI

OBJETIVO: Evaluar la relación entre el consumo de antibióticos antipseudomonales y la tasa de resistencia de cada fármaco individual en cepas de Pseudomonas aeruginosa aisladas en infecciones relacionadas con dispositivos invasivos (IDRI, por sus siglas en inglés) adquiridas en la unidad de cuidados intensivos (UCI). DISEÑO: Análisis post-hoc de los datos recopilados prospectivamente del registro ENVIN-HELICS. Ámbito: Las UCI que participaron en el registro ENVIN-UCI entre los años 2007-2016 (registro de 3 meses cada año). PACIENTES: Pacientes ingresados >24h. VARIABLES PRINCIPALES: Se calcularon las tendencias anuales lineales y no lineales de las tasas de resistencia de las cepas de P. aeruginosa identificadas en IDRI y los días de tratamiento de cada familia de antibióticos antipseudomonales por 1.000 días de cama ocupada en la UCI (DOT). RESULTADOS: Se diagnosticaron 15.095 episodios de IDRI en 11.652 pacientes (6,2% de 187.100). Se identificó P. aeruginosa en 2.095 (13,6%) de 15.432 patógenos que causaron IDRI. La resistencia aumentó significativamente durante el período de estudio para piperacilina-tazobactam (p < 0,001), imipenem (p = 0,016), meropenem (p = 0,004), ceftazidima (p = 0,005) y cefepima (p = 0,015), mientras que las variaciones en las tasas de resistencia de amikacina, ciprofloxacina, levofloxacina y colistina no fueron significativas. Se observó una disminución significativa de la DOT para aminoglucósidos (p < 0,001), cefalosporinas (p < 0,001), quinolonas (p < 0,001) y carbapenems (p < 0,001). CONCLUSIONES: No se encontró asociación significativa del consumo de cada familia de antibióticos antipseudomonales con sus respectivas tasas de resistencia para las cepas de P. aeruginosa identificadas en IDRI

Changes of resistance rates in Pseudomonas aeruginosa strains are unrelated to antimicrobial consumption in ICU populations with invasive device-related infection.

OBJECTIVE: To evaluate the relationship between antipseudomonal antibiotic consumption and each individual drug resistance rate in Pseudomonas aeruginosa strains causing ICU acquired invasive device-related infections (IDRI). DESIGN: A post hoc analysis was made of the data collected prospectively from the ENVIN-HELICS registry. SETTING: Intensive Care Units participating in the ENVIN-UCI registry between the years 2007 and 2016 (3-month registry each year). PATIENTS: Patients admitted for over 24h. MAIN VARIABLES: Annual linear and nonlinear trends of resistance rates of P. aeruginosa strains identified in IDRI and days of treatment of each antipseudomonal antibiotic family per 1000 occupied ICU bed days (DOT) were calculated. RESULTS: A total of 15,095 episodes of IDRI were diagnosed in 11,652 patients (6.2% out of a total of 187,100). Pseudomonas aeruginosa was identified in 2095 (13.6%) of 15,432 pathogens causing IDRI. Resistance increased significantly over the study period for piperacillin-tazobactam (P<0.001), imipenem (P=0.016), meropenem (P=0.004), ceftazidime (P=0.005) and cefepime (P=0.015), while variations in resistance rates for amikacin, ciprofloxacin, levofloxacin and colistin proved nonsignificant. A significant DOT decrease was observed for aminoglycosides (P<0.001), cephalosporins (P<0.001), quinolones (P<0.001) and carbapenems (P<0.001). CONCLUSIONS: No significant association was observed between consumption of each antipseudomonal antibiotic family and the respective resistance rates for P. aeruginosa strains identified in IDRI.

¿Es necesario un proyecto para prevenir las infecciones del tracto urinario en los pacientes ingresados en unidades de cuidados intensivos españolas? / Is a project needed to prevent urinary tract infection in patients admitted to spanish ICUs?

Objetivo: Analizar los datos epidemiológicos de las infecciones del tracto urinario relacionadas con sonda uretral (ITU-SU) en pacientes críticos ingresados en UCI españolas para evaluar la necesidad de aplicar un programa de intervención a nivel nacional para disminuir dichas infecciones. Diseño: Análisis retrospectivo, no intervencionista, de prevalencia de periodo anual. Ámbito: UCI participantes en el registro multicéntrico ENVIN-UCI entre los años 2007-2016. Pacientes: Pacientes críticos ingresados en UCI con ITU-SU. Variables principales: Tasa de incidencia por 1.000 días de utilización de SU; ratio de uso de SU; proporción de ITU-SU con respecto del total de infecciones relacionadas con asistencia sanitaria (IRAS) controladas en el registro. Resultados: Se han incluido 187.100 pacientes de los que 137.654 (73,6%) utilizaron SU durante 1.215.673 días (84,4% de los días de estancia en UCI). En 4.539 (3,3%) pacientes sondados se han diagnosticado 4.977 ITU-SU (3,6 episodios por 100 pacientes con SU). La tasa de incidencia de ITU-SU ha disminuido entre los años 2007 y 2016 un 19% (4,69 a 3,8 episodios por 1.000 días de SU), aunque se ha mantenido la ratio de uso de SU (0,84 [0,82-0,86]). La proporción de las ITU-SU ha aumentado desde el 23,3% al 31,9% del total de IRAS controladas. Conclusiones: Aunque han disminuido las tasas de ITU-SU estas infecciones han pasado a ser, proporcionalmente, la primera de las IRAS en UCI. Persiste una elevada ratio de utilización de SU en UCI españolas. Existe un espacio de mejora, por lo que un proyecto ITU-ZERO podría ser útil en nuestro país

Objective: To analyze epidemiological data of catheter-associated urinary tract infection (CAUTI) in critically ill patients admitted to Spanish ICUs in order to assess the need of implementing a nationwide intervention program to reduce these infections. Design: Non-intervention retrospective annual period prevalence analysis. Setting: Participating ICUs in the ENVIN-UCI multicenter registry between the years 2007-2016. Patients: Critically ill patients admitted to the ICU with catheter-associated urinary tract infection (CAUTI). Main variables: Incidence rates per 1,000 catheter-days; urinary catheter utilization ratio; proportion of CAUTIs in relation to total health care-associated infections (HAIs). Results: A total of 187,100 patients, 137,654 (73.6%) of whom had a urinary catheter in place during 1,215,673 days (84% of days of ICU stay) were included. In 4,539 (3.3%) patients with urinary catheter, 4,977 CAUTIs were diagnosed (3.6 episodes per 100 patients with urinary catheter). The CAUTI incidence rate showed a 19% decrease between 2007 and 2016 (4.69 to 3.8 episodes per 1,000 catheter-days), although a sustained urinary catheter utilization ratio was observed (0.84 [0.82-0.86]). The proportion of CAUTI increased from 23.3% to 31.9% of all HAIs controlled in the ICU. Conclusions: Although CAUTI rates have declined in recent years, these infections have become proportionally the first HAIs in the ICU. The urinary catheter utilization ratio remains high in Spanish ICUs. There is room for improvement, so that a CAUTI-ZERO project in our country could be useful

Is a project needed to prevent urinary tract infection in patients admitted to spanish ICUs? / ¿Es necesario un proyecto para prevenir las infecciones del tracto urinario en los pacientes ingresados en unidades de cuidados intensivos españolas?

OBJECTIVE: To analyze epidemiological data of catheter-associated urinary tract infection (CAUTI) in critically ill patients admitted to Spanish ICUs in order to assess the need of implementing a nationwide intervention program to reduce these infections. DESIGN: Non-intervention retrospective annual period prevalence analysis. SETTING: Participating ICUs in the ENVIN-UCI multicenter registry between the years 2007-2016. PATIENTS: Critically ill patients admitted to the ICU with catheter-associated urinary tract infection (CAUTI). MAIN VARIABLES: Incidence rates per 1,000 catheter-days; urinary catheter utilization ratio; proportion of CAUTIs in relation to total health care-associated infections (HAIs). RESULTS: A total of 187,100 patients, 137,654 (73.6%) of whom had a urinary catheter in place during 1,215,673 days (84% of days of ICU stay) were included. In 4,539 (3.3%) patients with urinary catheter, 4,977 CAUTIs were diagnosed (3.6 episodes per 100 patients with urinary catheter). The CAUTI incidence rate showed a 19% decrease between 2007 and 2016 (4.69 to 3.8 episodes per 1,000 catheter-days), although a sustained urinary catheter utilization ratio was observed (0.84 [0.82-0.86]). The proportion of CAUTI increased from 23.3% to 31.9% of all HAIs controlled in the ICU. CONCLUSIONS: Although CAUTI rates have declined in recent years, these infections have become proportionally the first HAIs in the ICU. The urinary catheter utilization ratio remains high in Spanish ICUs. There is room for improvement, so that a CAUTI-ZERO project in our country could be useful.

Invasive device-associated infections caused by Pseudomonas aeruginosa in critically ill patients: evolution over 10 years.

Invasive device-associated infections caused by Pseudomonas aeruginosa over 10 years (2007-2016) were assessed based on data from the ENVIN-HELICS registry (200 Spanish intensive care units). P. aeruginosa was the leading pathogen except in the last two years in which there was a slight decrease, with Escherichia coli as the leading aetiology. The rate of infections caused by P. aeruginosa remained between 12.0% and 14.6% throughout the study period. There was a significant increase of isolates resistant to imipenem, meropenem, ceftazidime, cefepime, and piperacillin-tazobactam. Multidrug-resistant and the sum of extensively drug- and pandrug-resistant strains also increased. Resistance to anti-pseudomonal antimicrobials remains a matter of concern.

Transcriptome analysis of severely active chronic spontaneous urticaria shows an overall immunological skin involvement.

BACKGROUND: The knowledge about chronic spontaneous urticaria (CSU) phenotypes is based on its clinical characteristics, associated comorbidities, course of the disease, and its response to the available effective drugs. Genotype expression and its further correlation with CSU phenotypes are still unknown. We describe the cutaneous transcriptome of patients suffering a severely active CSU refractory to antihistamine treatment. METHODS: Through the bioinformatic analysis of the whole Human Genome with Oligo Microarrays and quantitative real-time polymerase chain reaction (qPCR), relevant genes expressed in nonlesional (NLS-CSU) and lesional skin (LS-CSU) and peripheral blood were identified in 20 patients suffering from severely active CSU and 10 healthy controls (HCs). RESULTS: From 39 genes differentially expressed in NLS-CSU when compared with HCs, 31 (79.48%) were confirmed by qPCR corresponding to genes involved in epidermal homeostasis and dermal repair. From the analysis comparing LS-CSU with NLS-CSU, a selection of 142 genes was studied with qPCR, and 103 (72.53%) were confirmed. Differentially expressed genes in the phenomenon of wheal development are involved in a variety of biological functions as, epidermal differentiation, intracellular signal function, transcriptional factors cell cycle differentiation, inflammation, or coagulation. Differentially expressed genes that uniformly increase or decrease along the skin worsening until the wheal appearance is shown. CONCLUSION: The skin of CSU patients with a severely active disease shows an overall immunological skin involvement showing a peculiar gene profile.

Characteristics and outcomes of patients admitted to Spanish ICU: A prospective observational study from the ENVIN-HELICS registry (2006-2011) / Características y evolución de los pacientes ingresados en UCI españolas: un estudio observacional prospectivo del registro ENVIN-HELICS (2006-2011)

OBJECTIVE: To describe the case-mix of patients admitted to intensive care units (ICUs) in Spain during the period 2006-2011 and to assess changes in ICU mortality according to severity level. DESIGN: Secondary analysis of data obtained from the ENVN-HELICS registry. Observational prospective study. SETTING: Spanish ICU. Patients: Patients admitted for over 24h. Interventions: None. VARIABLES: Data for each of the participating hospitals and ICUs were recorded, as well as data that allowed to knowing the case-mix and the individual outcome of each patient. The study period was divided into two intervals, from 2006 to 2008 (period 1) and from 2009 to 2011 (period 2). Multilevel and multivariate models were used for the analysis of mortality and were performed in each stratum of severity level. RESULTS: The study population included 142,859 patients admitted to 188 adult ICUs. There was an increase in the mean age of the patients and in the percentage of patients > 79 years (11.2%vs. 12.7%, P < 0.001). Also, the mean APACHE II score increased from 14.35 ± 8.29 to 14.72 ± 8.43 (P < 0.001). The crude overall intra-UCI mortality remained unchanged (11.4%) but adjusted mortality rate in patients with APACHE II score between 11 and 25 decreased modestly in recent years (12.3% vs. 11.6%, odds ratio = 0.931, 95% CI 0.883-0.982; P = 0.008). Conclusion: This study provides observational longitudinal data on case-mix of patients admitted to Spanish ICUs. A slight reduction in ICU mortality rate was observed among patients with intermediate severity level

OBJETIVO: Describir el case-mix de los pacientes admitidos en las unidades de cuidados intensivos (UCI) españolas durante el periodo 2006-2011 y evaluar los cambios en la mortalidad en UCI según el nivel de gravedad. DISEÑO: Estudio prospectivo y observacional. Análisis secundario procedente del registro ENVIN-HELICS. ÁMBITO: ICU españolas. PACIENTES: Pacientes ingresados más de 24h. Intervención: Ninguna. Variables: Se registraron los datos de cada UCI participante, así como aquellos que permiten conocer el case-mix y el estado al alta de cada paciente. El periodo de estudio se dividió en 2 intervalos, de 2006 a 2008 (periodo 1) y de 2009 a 2011 (periodo 2). Para el análisis de la mortalidad y en cada estrato de nivel de gravedad se realizó un estudio multivariante y multinivel. Resultados: La población estudiada incluye 142.859 pacientes ingresados en 188 UCI de adultos. Se apreció un incremento en la media de edad de los pacientes, así como en el porcentaje de los que eran mayores de 79 años (11,2 vs. 12,7%; p < 0,001). La media de APACHE II se incrementó de 14,35 ± 8,29 a 14,72 ± 8,43 (p < 0,001). La mortalidad bruta no varió (11,4%), pero la mortalidad ajustada en pacientes con APACHE II entre 11 y 25 disminuyó modestamente en los últimos años (12,3 vs. 11,6%, odds ratio = 0,931, IC 95% 0,883-0,982; p = 0,008). CONCLUSIONES: Este estudio proporciona datos observacionales del case-mix de los pacientes ingresados en las UCI de España. Se observa una ligera reducción de la mortalidad en los pacientes con un grado intermedio en la escala de gravedad

Characteristics and outcomes of patients admitted to Spanish ICU: A prospective observational study from the ENVIN-HELICS registry (2006-2011).

OBJECTIVE: To describe the case-mix of patients admitted to intensive care units (ICUs) in Spain during the period 2006-2011 and to assess changes in ICU mortality according to severity level. DESIGN: Secondary analysis of data obtained from the ENVN-HELICS registry. Observational prospective study. SETTING: Spanish ICU. PATIENTS: Patients admitted for over 24h. INTERVENTIONS: None. VARIABLES: Data for each of the participating hospitals and ICUs were recorded, as well as data that allowed to knowing the case-mix and the individual outcome of each patient. The study period was divided into two intervals, from 2006 to 2008 (period 1) and from 2009 to 2011 (period 2). Multilevel and multivariate models were used for the analysis of mortality and were performed in each stratum of severity level. RESULTS: The study population included 142,859 patients admitted to 188 adult ICUs. There was an increase in the mean age of the patients and in the percentage of patients >79 years (11.2% vs. 12.7%, P<0.001). Also, the mean APACHE II score increased from 14.35±8.29 to 14.72±8.43 (P<0.001). The crude overall intra-UCI mortality remained unchanged (11.4%) but adjusted mortality rate in patients with APACHE II score between 11 and 25 decreased modestly in recent years (12.3% vs. 11.6%, odds ratio=0.931, 95% CI 0.883-0.982; P=0.008). CONCLUSION: This study provides observational longitudinal data on case-mix of patients admitted to Spanish ICUs. A slight reduction in ICU mortality rate was observed among patients with intermediate severity level.

Análisis comparativo de pacientes ingresados en Unidades de Cuidados Intensivos españolas por causa médica y quirúrgica / Comparative analysis of patients admitted to Spanish Intensive Care Units due to medical and surgical disease

OBJETIVO: Describir el case-mix de los pacientes médicos y quirúrgicos ingresados en UCI y comparar ambas poblaciones. DISEÑO: Análisis de datos de pacientes ingresados en UCI entre 2006 y 2011, extraídos del registro ENVIN-HELICS. Estudio observacional, prospectivo, multicéntrico y de participación voluntaria. Ámbito: Ciento ochenta y ocho Unidades de Cuidados Intensivos españolas. PARTICIPANTES: Pacientes ingresados durante más de 24 h. Variables de interés principales: Datos demográficos, causa de ingreso, escalas de gravedad, tiempo de estancia y mortalidad. RESULTADOS: Se analiza a 138.999 pacientes. El motivo de ingreso era médico no coronario en 65.467 (47,1%), coronario en 27.785 (20,0%), postoperatorio de cirugía programada en 28.044 (20,2%) y urgente en 17.613 (12,7%). Los pacientes quirúrgicos urgentes precisan mayor utilización de dispositivos y presentan más infecciones nosocomiales y por patógenos multirresistentes. La mediana de estancia en UCI es más prolongada en estos pacientes (5 días; rango intercuartílico: 2-11), así como la media de APACHE II y SAPS II. La mortalidad global es superior en pacientes médicos no coronarios (16,6%). Categorizando a los pacientes según el valor APACHE II, la mortalidad es mayor para todos los niveles en los pacientes quirúrgicos urgentes que en los programados, dándose la mayor diferencia en aquellos con APACHE II entre 6 y 10: el 3 y el 0,9%, respectivamente; OR: 2,141 (IC del 95%, 1,825-2,513); p < 0,001. CONCLUSIONES: Los pacientes médicos no coronarios presentan mayor mortalidad, pero son los quirúrgicos urgentes los que precisan mayor uso de recursos por paciente. La escala APACHE II infraestima la mortalidad en pacientes quirúrgicos urgentes

OBJECTIVE: To describe the characteristics of the patients case-mix admitted to ICUs due to medical and surgical disease, and to compare both groups. DESIGN: Analysis of data covering the period 2006-2011 in the ENVIN-HELICS registry. An observational, prospective, multicenter and voluntary participation study. Setting: A total of 188 Spanish ICUs. Patients: All patients admitted for more than 24 hours. MAIN VARIABLES: Demographic data, cause of admission, severity scores, length of stay, mortality. RESULTS: A total of 138,999 patients were analyzed. Of these, 65,467 (47.1%) were admitted due to a non-coronary medical cause, 27,785 (20,0%) due to coronary-related illness, 28,044 (20,2%) after elective surgery and 17,613 (12.7%) after urgent surgery. Use of devices, nosocomial infections and isolation of multirresistant organisms were more prevalent in urgent surgery patients. Longer length of stay (median 5 days; interquartile range 2-11) as well as higher severity scale values (APACHE II and SAPS II) corresponded to this same group of patients. Mortality was higher in non-coronay medical patients. On categorizing the patients according to the APACHE II score, mortality was seen to be higher in urgent surgery cases than in elective surgery patients in all groups. The largest difference was observed in the APACHE II score 6-10 group (3% vs. 0.9%) (OR: 2.14, 95% CI 1.825-2.513; p<0.001). CONCLUSIONS: The mortality rate is higher in non-coronary medical patients, though resource use per patient is greater in the urgent surgery cases. The APACHE II scale underestimates mortality in emergency surgery patients

Intensive care practices in brain death diagnosis and organ donation.

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

[Comparative analysis of patients admitted to Spanish Intensive Care Units due to medical and surgical disease]. / Análisis comparativo de pacientes ingresados en Unidades de Cuidados Intensivos españolas por causa médica y quirúrgica.

OBJECTIVE: To describe the characteristics of the patients case-mix admitted to ICUs due to medical and surgical disease, and to compare both groups. DESIGN: Analysis of data covering the period 2006-2011 in the ENVIN-HELICS registry. An observational, prospective, multicenter and voluntary participation study. SETTING: A total of 188 Spanish ICUs. PATIENTS: All patients admitted for more than 24 hours. MAIN VARIABLES: Demographic data, cause of admission, severity scores, length of stay, mortality. RESULTS: A total of 138,999 patients were analyzed. Of these, 65,467 (47.1%) were admitted due to a non-coronary medical cause, 27,785 (20,0%) due to coronary-related illness, 28,044 (20,2%) after elective surgery and 17,613 (12.7%) after urgent surgery. Use of devices, nosocomial infections and isolation of multirresistant organisms were more prevalent in urgent surgery patients. Longer length of stay (median 5 days; interquartile range 2-11) as well as higher severity scale values (APACHE II and SAPS II) corresponded to this same group of patients. Mortality was higher in non-coronay medical patients. On categorizing the patients according to the APACHE II score, mortality was seen to be higher in urgent surgery cases than in elective surgery patients in all groups. The largest difference was observed in the APACHE II score 6-10 group (3% vs. 0.9%) (OR: 2.14, 95% CI 1.825-2.513; p<0.001). CONCLUSIONS: The mortality rate is higher in non-coronary medical patients, though resource use per patient is greater in the urgent surgery cases. The APACHE II scale underestimates mortality in emergency surgery patients.

Quantitative assessment of the Salmonella distribution on fresh-cut leafy vegetables due to cross-contamination occurred in an industrial process simulated at laboratory scale.

Fecal pathogen distributions in fresh-cut leafy vegetables are essential to develop suitable sampling plans so as to detect pathogen contaminations. In this study, a typical fresh-cut lettuce process was reproduced at pilot scale with different initial inoculum levels of Salmonella on lettuce (6-7, 4 and 1 log CFU/g). The pathogen was determined in all processed lettuce samples (n ≥ 50) and obtained count data were used to fit different probability distributions. The study showed that Salmonella is homogenously distributed on fresh-cut leafy vegetables as a result of processing (mainly washing) at all contamination levels. Negative binomial and Poisson-lognormal distributions were suitable to describe pathogen distribution at the high and medium levels. coefficient of variation modified (CV) indicated no overdispersion (i.e. clustering). Nevertheless, further research will be needed to assess the effect of using disinfectants in washing water on the final distribution pattern of pathogens in processed fresh-cut leafy vegetables.

Urethral catheter-related urinary infection in critical patients admitted to the ICU. Descriptive data of the ENVIN-UCI study.

OBJECTIVE: To describe trends in national catheter-related urinary tract infection (CRUTI) rates, as well as etiologies and multiresistance markers. DESIGN: An observational, prospective, multicenter voluntary participation study was conducted from 1 April to 30 June in the period between 2005 and 2010. SETTING: Intensive Care Units (ICUs) that participated in the ENVIN-ICU registry during the study period. PATIENTS: We included all patients admitted to the participating ICUs and patients with urinary catheter placement for more than 24 hours (78,863 patients). INTERVENTION: Patient monitoring was continued until discharge from the ICU or up to 60 days. VARIABLES OF INTEREST: CRUTIs were defined according to the CDC system, and frequency is expressed as incidence density (ID) in relation to the number of urinary catheter-patients days. RESULTS: A total of 2329 patients (2.95%) developed one or more CRUTI. The ID decreased from 6.69 to 4.18 episodes per 1000 days of urinary catheter between 2005 and 2010 (p<0.001). In relation to the underlying etiology, gramnegative bacilli predominated (55.6 to 61.6%), followed by fungi (18.7 to 25.2%) and grampositive cocci (17.1 to 25.9%). In 2010, ciprofloxacin-resistant E. coli strains (37.1%) increased, as well as imipenem-resistant (36.4%) and ciprofloxacin-resistant (37.1%) strains of P. aeruginosa. CONCLUSIONS: A decrease was observed in CRUTI rates, maintaining the same etiological distribution and showing increased resistances in gramnegative pathogens, especially E. coli and P. aeruginosa.

Modelling survival kinetics of Staphylococcus aureus and Escherichia coli O157:H7 on stainless steel surfaces soiled with different substrates under static conditions of temperature and relative humidity.

The survival of Escherichia coli O157:H7 and Staphylococcus aureus on stainless steel surfaces with Saline Solution (SS), Tryptone Soy Broth (TSB) and meat purge was studied, and based on results, mathematical models describing survival of pathogens as a function of time were proposed. Results indicated that S. aureus was able to survive longer than E. coli O157:H7 in all substrates. The type of substrate had a greater impact on the survival of E. coli O157:H7. This microorganism only remained viable for 8 and 50 h (hours) on surfaces with SS and TSB, respectively while on meat purge, the microorganism could be recovered after 200 h. For S. aureus, SS and TSB led to similar survival times (250 h) whereas on meat purge, survival capacity increased to 800 h. Survival data for S. aureus could be well described by a log-linear model or a Weibull model depending on the type of substrate (R(2) > 0.85). E. coli O157:H7 displayed an evident tail zone which made the Weibull model more appropriate (R(2) > 0.94). These survival models may be used in quantitative risk assessment to produce more accurate risk estimates. Finally, the results highlight the importance of performing effective cleaning procedures to prevent cross contamination.

Development of a risk-based methodology for estimating survival and growth of enteropathogenic Escherichia coli on iceberg-lettuce exposed at short-term storage in foodservice centers.

Ready-to-eat lettuce is a food commodity prone to contamination by pathogenic microorganisms if processing and distribution conditions as well as handling practices are not effective. A challenge testing protocol was applied to ready-to-eat iceberg-lettuce samples by inoculating different initial contamination levels (4.5, 3.5 and 2.5 log cfu/g) of Escherichia coli strain (serotype O158:H23) subsequently stored at 8, 12, 16, 20 and 24°C for 6h. A polynomial regression model for log difference (log(diff)) was developed at each inoculum level studied through the calculation of the effective static temperature (T(eff)). Furthermore, the developed model was integrated within a risk-based approach with real time/Temperature (t/T) data collected in three Spanish foodservice centers: school canteens, long-term care facilities (LTCF) and hospitals. Statistical distributions were fitted to t/T data and estimated log(diff) values were obtained as model outputs through a Monte Carlo simulation (10,000 iterations). The results obtained at static conditions indicated that the maintenance of the lettuce at 8°C slightly reduced the E. coli population from -0.4 to -0.5 log cfu/g. However, if chill chain is not maintained, E. coli can grow up to 1.1 log cfu/g at temperatures above 16°C, even at low contamination levels. Regarding log(diff) estimated in foodservice centers, very low risk was obtained (log(diff)<1.0 log cfu in all cases). Mean T(eff) values obtained in hospitals were the lowest ones (11.1°C) and no growth of E. coli was predicted in >92% of simulated cases. The results presented in this study could serve food operators to set time/Temperature requirements for ready-to-eat foods in foodservice centers, providing a scientific basis through the use of predictive modeling. These findings may also serve to food safety managers to better define the control measures to be adopted in foodservice centers in order to prevent food-borne infections.