Evaluación de la satisfacción del paciente con la atención recibida en un servicio de urgencias hospitalario y sus factores asociados / Patient evaluation of quality of emergency department care and associated factors

OBJETIVO: Conocer el grado de satisfacción global de los usuarios de un servicio de urgencias hospitalario (SUH) y analizar los factores que podían haber influido en la percepción de dicho grado de satisfacción. MÉTODO: Estudio de cohortes prospectivo basado en una encuesta a un grupo de pacientes menores de 65 años dados de alta desde el SUH durante marzo del 2011. Variable dependiente: "En términos de satisfacción, ¿cómo calificaría globalmente su experiencia en el servicio de urgencias?". Se registraron edad, sexo, día de la semana y nivel de triaje. La encuesta incluía la valoración del tiempo de espera; si era la primera vez que acudía al SUH; si se le había atendido con respeto y dignidad; si fue informado suficientemente; el trato del personal (administrativo, enfermería y médico); la información recibida de administrativos, enfermeros y médicos; y la limpieza, temperatura ambiente, luz y ruido del SUH. Se efectuó un análisis de regresión logística multinomial con las variables significativas. RESULTADOS: Se encuestaron 373 pacientes: 158 (42,4%) contestaron que su experiencia había sido totalmente satisfactoria, 187 (50,1%) satisfactoria y 28 (7,5%) no satisfactoria. Después del análisis multivariante, las variables que influían en una percepción no satisfactoria fueron la percepción de un tiempo de espera largo, un trato médico desconsiderado y la percepción de no reciber un trato respetuoso. CONCLUSIONES: En la población estudiada, el grado de satisfacción con la atención en urgencias, que suele ser elevado, está condicionado mayormente por la percepción del tiempo de espera, el trato médico recibido y un trato respetuoso (AU)

OBJECTIVE: To assess the level of patients' overall satisfaction with emergency department care and to analyze factors that may influence their perception of quality. METHOD: Prospective study of a cohort of patients under the age of 65 years who were discharged from the emergency department in March 2011. The patients' answers to the following question served as the dependent variable: How would you assess your overall satisfaction with your experience in our emergency department? Independent variables were age, sex, day of the week, and assigned triage level. The survey also contained questions asking for evaluation of wait time, if the emergency department visit was the patient's first, if the patient's dignity had been respected, if the patient felt adequately informed, how staff (administrative personnel, nurses, physicians) had behaved and if they gave sufficient information, and patients' impressions of the emergency department premises (cleanliness, temperature, lighting, noise level). Multinomial logistic regression was performed on significant variables. RESULTS: A total of 373 patients were surveyed; 158 (42.4%) evaluated their experience as completely satisfactory, 187(50.1%) as satisfactory, and 28 (7.5%) as unsatisfactory. After regression analysis, the variables found to be associated with perceived dissatisfaction were a prolonged wait time, inconsiderate treatment by a physician, and a feeling of not being respected. CONCLUSIONS: Level of satisfaction, which was high in general in this cohort, is influenced mainly by perception of wait time, the physician's attitude, and a sense of being respected (AU)

Expanded allogeneic adipose-derived stem cells (eASCs) for the treatment of complex perianal fistula in Crohn's disease: results from a multicenter phase I/IIa clinical trial.

PURPOSE: The management of perianal fistula in patients with Crohn's disease is an extremely challenging medical problem as many fistulas do not respond to available treatments. The objectives were to assess the safety and efficacy of a suspension of expanded adipose-derived allogeneic mesenchymal stem cells (eASCs) for the treatment of complex perianal fistula in Crohn's disease METHODS: An open-label, single-arm clinical trial was conducted at six Spanish hospitals. Twenty-four patients were administered intralesionally with 20 million eASCs in one draining fistula tract. A subsequent administration of 40 million eASCs was performed if fistula closure was incomplete at week 12. Subjects were followed until week 24 after the initial administration. RESULTS: Treatment-related adverse events did not indicate any clinical safety concerns after 6 months follow-up. The full analysis of efficacy data at week 24 showed 69.2 % of the patients with a reduction in the number of draining fistulas, 56.3 % of the patients achieved complete closure of the treated fistula achieved, and 30 % of the cases presenting complete closure of all existing fistula tracts. Of note, closure was strictly defined as: absence of suppuration through the external orifice and complete re-epithelization, plus absence of collections measured by magnetic resonance image scan (MRI). Furthermore, MRI Score of Severity showed statistically significant differences at week 12 with a marked reduction at week 24. CONCLUSIONS: Locally injected eASCs appear to be a simple, safe, and beneficial therapy for perianal fistula in Crohn's disease patients. Additional studies are needed to further confirm the efficacy of the eASCs.

Intrahepatic biliary lesions after orthotopic liver transplantation.

Intrahepatic biliary lesions (IBL) are rare (2-9%) after orthotopic liver transplantation (OLT). The aim was to evaluate the incidence, etiology and outcome. In nine years, a total 532 OLTs were performed in 481 patients. Twenty-four patients developed IBL. Eight were due to HAT, seven to ABOI, three to CDR and six to PI. The time until diagnosis of HAT is longest in patients (14+/-6) with IBL. ABOI is another cause of IBL. CDR is a rare cause of IBL, however when it takes place, patients must undergo Rtx. Finally, PI is a relevant cause of IBL. In order to suppress the incidence of IBL we should consider 1) the systematic use of Doppler-Ultrasound; 2) emergency reoperation of patients with HAT, 3) avoid ABOI in OLT; 4) Rtx in cases of CDR, and 5) OLT should still be performed as an emergency procedure.

Síndrome del latigazo cervical

El término 'síndrome del latigazo cervical' se utiliza para describir la lesión de uno o más elementos de la región del cuello, que puede ocurrir cuando se aplican fuerzas de inercia sobre la cabeza en un accidente de un vehículo a motor y que ocasiona dolor en la región cervical. Suele reservarse esta denominación cuando no se aprecian signos de lesión de la columna cervical en las exploraciones radiológicas y en ausencia de signos de lesión de las raíces nerviosas. Es un diagnóstico de exclusión que debe efectuarse una vez se han descartado otras lesiones más graves (AU)

L-arginine reduces liver and biliary tract damage after liver transplantation from non-heart-beating donor pigs.

BACKGROUND: To evaluate whether L-arginine reduces liver and biliary tract damage after transplantation from non heart-beating donor pigs. METHODS: Twenty-five animals received an allograft from non-heart-beating donors. After 40 min of cardiac arrest, normothermic recirculation was run for 30 min. The animals were randomly treated with L-arginine (400 mg x kg(-1) during normothermic recirculation) or saline (control group). Then, the animals were cooled and their livers were transplanted after 6 hr of cold ischemia. The animals were killed on the 5th day, liver damage was assessed on wedged liver biopsies by a semiquantitative analysis and by morphometric analysis of the necrotic areas, and biliary tract damage by histological examination of the explanted liver. RESULTS: Seventeen animals survived the study period. The histological parameters assessed (sinusoidal congestion and dilatation, sinusoidal infiltration by polymorphonuclear cells and lymphocytes, endothelitis, dissociation of liver cell plates, and centrilobular necrosis) were significantly worse in the control group. The necrotic area affected 15.9 +/- 14.5% of the liver biopsies in the control group and 3.7 +/- 3.1% in the L-arginine group (P<0.05). Six of eight animal in the control group and only one of eight survivors in the L-arginine group developed ischemic cholangitis (P<0.01). L-Arginine administration was associated with higher portal blood flow (676.9 +/- 149.46 vs. 475.2 +/- 205.6 ml x min x m(-2); P<0.05), higher hepatic hialuronic acid extraction at normothermic recirculation (38.8 +/- 53.7% vs. -4.2 +/- 18.2%; P<0.05) and after reperfusion (28.6 +/- 55.5% vs. -10.9 +/- 15.5%; P<0.05) and lower levels of alpha-glutation-S-transferase at reperfusion (1325 +/- 1098% respect to baseline vs. 6488 +/- 5612%; P<0.02). CONCLUSIONS: L-Arginine administration during liver procurement from non heart beating donors prevents liver and biliary tract damage.

Valoración de la radioterapia preoperatoria como tratamiento coadyuvante en el cáncer de recto. resultados preliminares / Assessment of preoperative radiotherapy as adjuvant therapy in the treatment of rectal cancer. Preliminary results

Introducción. La utilización de la radioterapia como tratamiento coadyuvante del cáncer de recto es actualmente un tema de controversia. El objetivo de este estudio es analizar los resultados con la utilización de la radioterapia preoperatoria en pacientes afectados de neoplasia de recto resecable comparándolos con un grupo de pacientes intervenidos de neoplasia de recto sin tratamiento complementario preoperatorio. Pacientes y métodos. Se analizan los resultados de una serie prospectiva de 63 pacientes con neoplasia de recto y sometidos a radioterapia preoperatoria, comparados con una serie retrospectiva de 61 pacientes con el mismo diagnóstico a los que no se realizó radioterapia previa a la cirugía. Resultados. No se han hallado diferencias significativas en la tasa de complicaciones postoperatorias de ambos grupos. La tasa de recidiva local fue menor en el grupo de radioterapia preoperatoria (3,17 por ciento) que en el grupo de cirugía (14,75 por ciento), con significación estadística (p = 0,016). Conclusiones. La utilización de radioterapia preoperatoria como tratamiento coadyuvante del cáncer rectal no se asocia a un aumento de la morbididad postoperatoria. Nuestros resultados sugieren una menor tasa de recidivas locales asociada al uso de radioterapia preoperatoria (AU)

Evaluation of ischemic injury during liver procurement from non-heart-beating donors.

UNLABELLED: The aim of this study was to assess liver viability after different periods of cardiac arrest and the predictive value of two markers of ischemia-reperfusion injury. METHODS: A pig liver transplantation model of non-heart-beating donors was studied. Four donor groups were designed; three groups were submitted to different periods of cardiac arrest (20, 30 and 40 min), and the fourth group served as the control group (without cardiac arrest). In the non-heart-beating donor groups, normothermic recirculation was established 30 min prior to total body cooling. Aminotransferase, alpha-glutathione-S-transferase, and hyaluronic acid determinations as well as liver biopsies, were serially performed. RESULTS: Although hepatocellular function could be preserved after 40 min of cardiac arrest, histological lesions at 5 days were considered irreversible due to the presence of a necrotic biliary tract. An overall significant relationship was found between the time period of cardiac arrest (20, 30 or 40 min) and the levels of hyaluronic acid (p = 0.004) or alpha-glutathione-S-transferase (p = 0.01) obtained during liver procurement and transplantation. CONCLUSIONS: The period of cardiac arrest is the determinant factor of liver viability after liver transplantation from non-heart-beating donors. As early markers of endothelial or hepatocellular damage, hyaluronic acid or alpha-glutathione-S-transferase levels may help to evaluate the ischemic injury of a potential donor.

Liver conditioning after cardiac arrest: the use of normothermic recirculation in an experimental animal model.

The aim of this study was to compare the possible role of normothermic recirculation with the role of liver transplants from non-heart-beating donor pigs after 20 min of cardiac arrest. Three groups were studied, of which two were control groups: group 1, in which the liver was harvested from a heart-beating donor; group 2, in which the liver was harvested after a period of cardiac arrest followed by total body cooling; and group 3, in which the liver was procured as in group 2, but including a period of 30 min of cardiopulmonary bypass and tissue oxygenation at 37 degrees C before total body cooling. Survival at 5 days; endothelial (hyaluronic acid) and hepatocellular damage (AST, ALT, and alpha-GST); adenine nucleotides (energy charge), and histological changes were evaluated. Normothermic recirculation during 30 min showed a significant effect on survival (p = .03), endothelial damage (p < .05), and histological changes after reperfusion (p = .04). Cardiopulmonary bypass significantly increased the energy charge during the normothermic recirculation period (p = .001). Moreover, this study shows that a significant survival (100%) can be achieved with a liver allograft after 20 min of cardiac arrest. Although the liver suffers a major insult in terms of endothelial damage and hepatocellular damage, lesions caused by the ischemic injury are reversible. Histological changes also indicate lesion reversibility, since they almost disappear after 5 days.

Hepatic blood flow and oxygen extraction ratio during normothermic recirculation and total body cooling as viability predictors in non-heart-beating donor pigs.

BACKGROUND: Our aim was to evaluate the hepatic blood flows and oxygen metabolism of non-heart-beating donor (NHBD) pigs, with the use of cardiopulmonary bypass (CPB) and normothermic recirculation (NR) before total body cooling, and its relationship with recipient survival. METHODS: Thirty-five pigs were transplanted with an allograft from NHBDs. After warm ischemia (WI) time (20, 30, or 40 min), CPB and NR were run for 30 min. After this period, the animals were cooled to 15 degrees C. In the control group (20 min of WI), the period of NR was excluded. Liver procurement was then performed. RESULTS: Survival rate was 100% in the 20WI, 70% in the 30WI, and 50% in the 40WI. Control group survival rate was 0%. Hepatic artery blood flow and portal blood flow recovered during NR. Pump blood flow during CPB increased rapidly during NR and was significantly higher in the 20WI. When donors of the livers transplanted in "surviving pigs" (DSP) were compared with donors of the livers transplanted in "nonsurviving pigs" (DNSP), hepatic artery blood flow, portal blood flow, and pump blood flow were higher in the DSP. Hepatic oxygen extraction ratio increased in the three groups with respect to baseline values. Hepatic oxygen extraction ratio was lower in the 20WI than in the other groups and was lower in the DSP than in the DNSP. CONCLUSIONS: The use of a NR period before total body cooling improves survival of liver transplantation in NHBDs. Portal blood flow and pump blood flow measurements can predict the viability of the grafts.

Vena cava vascular reconstruction during orthotopic liver transplantation: a comparative study.

The aim of this study was to evaluate the influence of preserving the recipient's inferior vena cava during orthotopic liver transplantation (OLT) on hemodynamic alterations, blood component requirements, postoperative liver and renal function, as well as vascular-related complications. A total of 122 OLTs was studied. In 35 OLTs, venovenous bypass (BP) was used; in 35 OLTs, bypass was not used (NBP); and in 52 OLTs, the recipient's inferior vena cava was preserved (PC). Preservation of the inferior vena cava means that venous return is not compromised at any time during transplantation. The time of hepatectomy was not different among the three groups (208 +/- 11, 188 +/- 13, and 194 +/- 6 minutes for BP, NBP, and PC, respectively); however, the total operating time was significantly lower in PC patients (492 +/- 24, 459 +/- 18, and 419 +/- 10 minutes for BP, NBP, and PC, respectively; P = .004, ANOVA). Blood component requirements were significantly lower in patients with PC. For red blood cells, these were 15.2 +/- 2.6, 16 +/- 3.4, and 7.1 +/- 1.5 units for BP, NBP, and PC, respectively (P = .009, ANOVA), and for fresh-frozen plasma, these were 5.4 +/- .7, 5.8 +/- .9, and 3 +/- .4 L for BP, NBP, and PC, respectively (P = .005, ANOVA). Postoperative liver and renal function did not differ among the three groups. The incidence of surgical complications (bleeding and vascular) was similar. Preservation of the inferior vena cava of the recipient significantly reduces the magnitude of OLT.