Situación actual de la atención a las enfermedades emergentes en los servicios de urgencias hospitalarias españoles / Current status of medical care of emerging infectious diseases at hospital emergency services in Spain

Fundamento: Conocer la situación organizativa de los hospitales españoles de cara a facilitar la atención adecuadaen los servicios de urgencias (SUH) de los pacientes queacudan con sospecha de infecciones de origen tropical. Método: Estudio descriptivo transversal mediante cuestionario en formato Google Forms® enviado a los miembros delgrupo de INFURG-SEMES. Se estudiaron variables como eltamaño del hospital a través del número de camas, el númerode urgencias de patología tropical, la existencia de protocolos de medicina tropical, de pruebas diagnósticas urgentes otratamiento antimalárico. Resultados: Se envió el formulario a 75 hospitales, obteniendo respuesta de 42 servicios de urgencias (55%), pertenecientes a 10 comunidades autónomas. Veinticuatro (57,1%)tenían más de 500 camas. Solo cinco hospitales (11,9%) podían diagnosticar malaria y dengue las 24 horas. En 19 hospitales (45,3%) no existía ningún protocolo de enfermedadtropical. En siete hospitales (16,7%) se realizaban diez o másasistencias/día. En los hospitales de mayor tamaño era másfrecuente la existencia de un servicio de enfermedades infecciosas independiente del servicio de Medicina Interna, unaunidad de medicina tropical, un infectólogo de guardia y unmicrobiólogo de guardia. No existen diferencias estadísticamente significativas entre los hospitales de mayor y menortamaño en cuanto a la capacidad para realizar diagnósticos otratamiento adecuados durante las 24 horas. Conclusiones: La atención de la patología importada supone un volumen no despreciable de consultas en los SUH,donde en general, se observa una ausencia de protocolosespecíficos, en especial, el protocolo específico de malaria,así como de escasa disponibilidad de prueba diagnósticaurgente de malaria.(AU)

Background: The aim of this study is to determine the current status of Spanish Hospital Emergency Services (HES) indiagnosing and treating the most prevalent tropical diseases (TD) in Spain. Methods: A cross-sectional descriptive study was carriedout, using a questionnaire in Google Forms® sent to members of the INFURG-SEMES group. The following variableswere analyzed: the size of the hospital in terms of numberof beds, number of tropical disease emergencies, existenceof tropical medicine protocols, urgent diagnostic tests orantimalarial treatment. Results: The form was sent to 75 hospitals. Responses wereobtained from 42 emergency services (55%) in 10 Autonomous Communities. Twenty-four (57.1%) had >500 beds.Only five hospitals (11.9%) have the facilities to diagnosemalaria and dengue 24 hours a day. There was no tropicaldisease protocol in 19 (45.3%) hospitals. Seven (16.7%)hospitals had ≥ 10 attendances/day. Larger hospitals weremore likely to have an infectious disease unit independentfrom Internal Medicine service, along with a tropical medicine unit, and an on-call infectious disease specialist andmicrobiologist. There are no statistically significant differences between larger and smaller hospitals in terms of theircapacity to carry out appropriate diagnoses or treatmentsin 24 hours. Conclusion: Care and treatment of emerging diseases arenow a sizeable percentage of the consultations at an HES.Such units generally lack specific protocols, particularly formalaria. Urgent diagnostic testing for malaria is also needed.(AU)

[Current status of medical care of emerging infectious diseases at hospital emergency services in Spain].

BACKGROUND: The aim of this study is to determine the current status of Spanish Hospital Emergency Services (HES) in diagnosing and treating the most prevalent tropical diseases (TD) in Spain. METHODS: A cross-sectional descriptive study was carried out, using a questionnaire in Google Forms® sent to members of the INFURG-SEMES group. The following variables were analyzed: the size of the hospital in terms of number of beds, number of tropical disease emergencies, existence of tropical medicine protocols, urgent diagnostic tests or antimalarial treatment. RESULTS: The form was sent to 75 hospitals. Responses were obtained from 42 emergency services (55%) in 10 Autonomous Communities. Twenty-four (57.1%) had >500 beds. Only five hospitals (11.9%) have the facilities to diagnose malaria and dengue 24 hours a day. There was no tropical disease protocol in 19 (45.3%) hospitals. Seven (16.7%) hospitals had =?10 attendances/day. Larger hospitals were more likely to have an infectious disease unit independent from Internal Medicine service, along with a tropical medicine unit, and an on-call infectious disease specialist and microbiologist. There are no statistically significant differences between larger and smaller hospitals in terms of their capacity to carry out appropri-ate diagnoses or treatments in 24 hours. CONCLUSION: Care and treatment of emerging diseases are now a sizeable percentage of the consultations at an HES. Such units generally lack specific protocols, particularly for malaria. Urgent diagnostic testing for malaria is also needed.

Utility of Basal Regional Oximetry as an Early Predictor of Graft Failure After Liver Transplant.

INTRODUCTION: Adequate perfusion and oxygenation to liver graft after transplantation is essential for its viability. Hepatic oximetry (hepatic tissue oxygenation [LSrO2]) through near infrared spectroscopy (NIRS) can help by showing real time oxygen content of the graft. METHODS: In this prospective study, we enrolled 50 consecutive patients undergoing liver transplant surgery from deceased donors. Liver NIRS (LSrO2) was continuously measured for 24 hours then analyzed and correlated with other clinical data such as hemoglobin (Hb), mixed venous oxygen saturation, cardiac index (CI), central venous pressure, arterial gases, diuresis, blood lactate, liver biochemistry, and normalized index ratio (INR). Severity disease scales and cold-warm ischemia time were also measured, as well as Doppler ultrasound (DUS) at hour 24. A statistical analysis with IBM SPSS 22 using Pearson correlation was carried out. RESULTS: LSrO2 could anticipate serious bleeding and hemodynamic events showing a decrease >10% from basal data. We found a significant correlation between LSrO2 with CI at 3 hours (P=.044), hemoglobin (Hb) at hour 3 and 24 (P = .004 and P = .002, respectively), and with Apache II (P=.041). A significant correlation was also detected between cold ischemia and INR at hour 24 (P=.016). No correlation of LSrO2 was found with lactate, liver biochemistry, and DUS data.

[Efficacy of low-dose oxytocin during elective cesarean section]. / Eficacia de la oxitocina a dosis bajas en cesáreas electivas.

BACKGROUND AND OBJECTIVE: In cesarean section, the optimal dose of oxytocin to reduce the risk of hemorrhage with the least risk of adverse effects has yet to be defined. We studied the effects of using 2 different doses of oxytocin in women undergoing elective cesarean section under spinal anesthesia. The women had had no prior labor. MATERIAL AND METHODS: Randomized multicenter trial enrolling 104 patients classified as ASA 1. Following fetal extraction and coinciding with umbilical cord clamping, a group of 52 women received 1 IU of oxytocin followed by an infusion of 2.5 IU x h(-1); a second group of 52 women received a continuous infusion of 20 IU at a rate of 700 mlU x min(-1) followed by 10 IU x min(-1). We compared uterine contractility (assessed as absent, moderate, satisfactory), postoperative vaginal bleeding (absent, light, moderate, heavy), hemodynamics, and adverse effects after administration of oxytocin and fetal extraction (electrocardiographic abnormalities, nausea, vomiting, discomfort, headache, blushing, trembling, chills, or chest pain). RESULTS: No significant between-group differences in patient, obstetric, or anesthetic variables were detected. Uterine contraction was satisfactory in over 90% of the patients in both groups on initial assessment during surgery. After surgery, vaginal bleeding was absent or light in over 90% of the women. No significant differences in adverse events were detected between groups. CONCLUSIONS: The incidence of obstetric bleeding is not higher when a lower dose of oxytocin is used; the rate of postoperative adverse events also does not increase.

Eficacia de la oxitocina a dosis bajas en cesáreas electivas / Efficacy of low-dose oxytocin during elective cesarean section

Objetivos: La dosis óptima de oxitocina en cesáreas que permita reducir el riesgo de hemorragia con la menor incidencia de efectos adversos derivados de su empleo no está bien definida. Estudiamos diversos parámetros tras la administración de oxitocina a diferentes dosis en cesáreas electivas con anestesia subaracnoidea en pacientes sin trabajo previo de parto. Material y métodos: Estudio de 104 pacientes ASA 1 aleatorizado, descriptivo, observacional y prospectivo multicéntrico. El grupo 1 (n = 52) recibió tras la extracción fetal y coincidiendo con el clampaje del cordón umbilical 1 UI de oxitocina seguida de una perfusión de 2,5 UI.h–1, y el grupo 2 (n = 52) una infusión continua de 20 UI a un ritmo de 700 mUI.min–1 seguido posteriormente a 10 UI.h–1. Se analizó la contractilidad uterina (ausente, moderada, satisfactoria), hemorragia vaginal postoperatoria (ausente, leve, moderada, abundante), comportamiento hemodinámico y efectos secundarios tras administración de oxitocina tras la extracción fetal (alteraciones en el ECG, náuseas, vómitos, malestar general, cefalea, enrojecimiento, temblor, escalofríos o dolor torácico). Resultados: No hubo diferencias significativas entre ambos grupos en las variables antropométricas, obstétricas o anestésicas. Así, la contracción uterina fue satisfactoria en más del 90% de las pacientes desde la primera exploración intraoperatoria en ambos grupos. La hemorragia vaginal postquirúrgica se cuantificó como ausente o leve en más del 90% de las gestantes. Tampoco en la incidencia de efectos adversos de la oxitocina hubo diferencias significativas. Conclusiones: La administración de dosis bajas de oxitocina en la cesárea electiva no se acompaña de una mayor incidencia de hemorragia obstétrica que el uso de dosis mayores, sin influir en la aparición de efectos secundarios(AU)

Background and objective: In cesarean section, the optimal dose of oxytocin to reduce the risk of hemorrhage with the least risk of adverse effects has yet to be defined. We studied the effects of using 2 different doses of oxytocin in women undergoing elective cesarean section under spinal anesthesia. The women had had no prior labor. Material and methods: Randomized multicenter trial enrolling 104 patients classified as ASA 1. Following fetal extraction and coinciding with umbilical cord clamping, a group of 52 women received 1 IU of oxytocin followed by an infusion of 2.5 IU·h-1; a second group of 52 women received a continuous infusion of 20 IU at a rate of 700 mIU·min-1 followed by 10 IU·min-1. We compared uterine contractility (assessed as absent, moderate, satisfactory), postoperative vaginal bleeding (absent, light, moderate, heavy), hemodynamics, and adverse effects after administration of oxytocin and fetal extraction (electrocardiographic abnormalities, nausea, vomiting, discomfort, headache, blushing, trembling, chills, or chest pain). Results: No significant between-group differences in patient, obstetric, or anesthetic variables were detected. Uterine contraction was satisfactory in over 90% of the patients in both groups on initial assessment during surgery. After surgery, vaginal bleeding was absent or light in over 90% of the women. No significant differences in adverse events were detected between groups. Conclusions: The incidence of obstetric bleeding is not higher when a lower dose of oxytocin is used; the rate of postoperative adverse events also does not increase(AU)

Evidence of increased risk for leishmania infantum infection among HIV-seronegative intravenous drug users from southern Spain.

To assess the prevalence of markers of Leishmania infection, 93 intravenous drug users and 77 nonusers of intravenous drugs underwent a Leishmania skin test and a serum Leishmania antibody search. All participants were human immunodeficiency virus seronegative. The Leishmania skin test was positive in 24 intravenous drug users and in 10 non-users of intravenous drugs (P=0.038). Leishmania seropositivity was detected in 3 of 11 active intravenous drug users and in 3 of 82 former drug injectors (P=0.02). Positivity in the Leishmania skin test was associated with intravenous drug use (adjusted odds ratio, 2.33; 95% confidence interval, 1.03-5.24). The prevalence of Leishmania infection markers among intravenous drug users is higher than that among controls. This suggests that this parasite spreads through the sharing of needles.

Influence of highly active antiretroviral therapy on the outcome of subclinical visceral leishmaniasis in human immunodeficiency virus-infected patients.

Seventeen human immunodeficiency virus-infected patients who were harboring untreated subclinical visceral leishmaniasis (VL) were prospectively followed up. None of the 11 patients who received highly active antiretroviral therapy (HAART) presented with symptomatic VL during follow-up, whereas 2 out of 6 patients who received therapy other than HAART had an episode of overt kala-azar. These findings suggest that HAART does not induce the evolution of latent VL into symptomatic disease.

[Evaluation of new intraurethral occlusive depot (ORIS FEMININO) in the management of female stress urinary incontinence]. / Evaluación de un nuevo dispositivo oclusivo intrauretral (ORIS FEMENINO) en el manejo de la incontinencia urinaria de esfuerzo femenina.

OBJECTIVE: To determine the utility and safety of an intraurethral device (Oris Femenino) in the management of female stress urinary incontinence. METHODS: A prospective clinical study was conducted on 54 female patients, mean age 46.4 years, with stress urinary incontinence. The degree and severity of the incontinence was determined before and one month after treatment with the intraurethral device. The reasons for the dropouts were analyzed and the rehabilitative effects two months after treatment had been completed were evaluated in 22 patients. RESULTS: 83% of the patients who completed the study referred positive results. A significant improvement was demonstrated for the degree of incontinence as well as the number of absorbent pads used. Age and severity of incontinence inversely correlated with positive results. A correlation between the absence of a previous urethropexy and positive results was also found. The dropout rate was 44% (24 patients) and was chiefly due to symptomatic bacteriuria in 14 cases and the difficulty in fixation and degree of incontinence. A statistically significant reduction was found in the number of pads used in the group of patients evaluated two months after treatment had been completed. CONCLUSIONS: The intraurethral device analyzed in this study significantly reduced urinary incontinence. This method appears to be more effective in younger women who are not severely incontinent and have not previously undergone urethropexy. The intraurethral device appears to have some rehabilitative effect on the perineal muscle. Symptomatic bacteriuria was found to be the main disadvantage.

Prevalence of and factors associated with visceral leishmaniasis in human immunodeficiency virus type 1-infected patients in southern Spain.

The actual prevalence of visceral leishmaniasis among human immunodeficiency type 1 (HIV-1)-infected patients in the Mediterranean basin remains unknown. There is also controversy about the risk factors for Leishmania infantum and HIV-1 coinfection. To appraise the prevalence of visceral leishmaniasis in patients infected with HIV-1 in southern Spain and to identify factors associated with this disease, 291 HIV-1 carriers underwent a bone marrow aspiration, regardless of their symptoms. Giemsa-stained samples were searched for Leishmania amastigotes. Thirty-two (11%) patients showed visceral leishmaniasis. Thirteen (41%) patients had subclinical cases of infection. Centers for Disease Control and Prevention (CDC) clinical category C was the factor most strongly associated with this disease (adjusted odds ratio [OR], 1.88 [95% confidence interval, 1.22 to 2.88]), but patients with subclinical cases of infection were found in all CDC categories. Female sex was negatively associated with visceral leishmaniasis (adjusted OR, 0.42 [95% confidence interval, 0.18 to 0.97]). Intravenous drug users showed a higher prevalence than the remaining patients (13.3 versus 4.9%; P = 0.04), but such an association was not independent. These results show that visceral leishmaniasis is a very prevalent disease among HIV-1-infected patients in southern Spain, with a high proportion of cases being subclinical. Like other opportunistic infections, subclinical visceral leishmaniasis can be found at any stage of HIV-1 infection, but symptomatic cases of infection appear mainly when a deep immunosuppression is present. There is also an association of this disease with male sex and intravenous drug use.

[Lymphoproliferative pathology of the genitourinary tract. Report of 6 cases and review of the literature]. / Patología linfoproliferativa del tracto genitourinario. Aportación de 6 casos y revisión de la literatura.

OBJECTIVES: Six cases of genitourinary lymphoma are described and the literature reviewed. METHODS/RESULTS: The cases had the following histopathological diagnosis: 1 small and large cell non-Hodgkin lymphoma (NHL) of the renal pelvis, 2 high grade centroblastic testicular NHL; 1 centroblastic-centroid bladder NHL, 1 lymphoplasmocytoid bladder NHL and 1 low grade NHL of the prostate. All but the prostatic lymphoma were primary. Treatment was by nephrectomy and chop polychemotherapy (PCT) for the renal pelvis NHL, orchiectomy for the 2 testicular NHLs (one case also received radiotherapy), chop PCT for the bladder NHLs and PCT for the prostatic NHL. Three patients have died: the patient with renal pelvis NHL, centroblastic-centroid bladder NHL and the patient with prostatic NHL. CONCLUSIONS: Although these tumors are rare, they should be suspected in patients with lymphoma, elderly men with a testicular mass, patients with a large bladder compressing/infiltrating mass and in the immunnodepressed patients. A preoperative histopathological diagnosis must be made before performing radical surgery.

[Continuing neurologic assessment in myelodysplasia]. / Evaluación neurourológica continuada en la mielodisplasia.

OBJECTIVES: Myelodysplasia produces a neurological lesion with unpredictable urodynamic sequelae. The present study describes our experience in 18 patients with myelodysplasia and vesicourethral dysfunction. METHODS: The study comprised 18 patients (11 males and 7 females) with myelodysplasia and vesicourethral dysfunction. Patient median age was 15.7 years (range 7 months-57 years) and the mean follow-up was 20 months (range 7-47 months). After physical and neurological examination, all patients underwent a complete urodynamic evaluation, including selective electromyography of the periurethral sphincter and videocystography. The urodynamic studies were repeated regularly during follow-up. RESULTS: 14 patients (67.7%) showed a lower motor neuron vesicourethral dysfunction; 2 (11.1%) had upper motor neuron lesion and 2 (11.1%) mixed motor neuron lesion. During the study period, no alterations were observed in the urodynamic pattern of patients with upper or mixed motor neuron lesions, but 9 patients (64.2%) with lower motor neuron lesions showed changes in the urodynamic pattern compared with the first evaluation, with alterations in bladder compliance being the most frequent. CONCLUSIONS: Alterations in bladder compliance may arise from neurogenic and nonneurogenic factors. Our findings indicate the need for close urodynamic surveillance of patients with myelodysplasia and vesicourethral dysfunction.

[Urothelial tumors of the upper urinary tract: epidemiologic study, diagnostic assessment, and treatment]. / Tumores uroteliales del tracto urinario superior: estudio epidemiológico, evaluación diagnóstica y terapéutica.

OBJECTIVES: The result of an epidemiological study and evaluation of diagnosis and treatment of transitional cell tumors of the upper urinary tract are presented. MATERIAL AND METHODS: A retrospective study was conducted on 34 patients with transitional cell tumor of the upper urinary tract. RESULTS: The most common symptom was intermittent hematuria. Smoking was found to be the most important risk factor and 41.7% of the cases previously had a bladder cancer. IVP was the diagnostic technique most commonly utilized (61.7%). Nephroureterectomy was performed in 58.8% of the cases. Six cases had recurrence of the upper urinary tract tumor. There were 9 deaths (26.5%). CONCLUSIONS: The epidemiological data are similar to those of larger series. The tumors appear to develop in the presence of generalized urothelial disease. The low incidence of recurrence in the ipsilateral ureteral meatus indicates that resection of the distal ureter may not be required in patients at high risk.

[Vesicourethral dysfunction in the acquired immunodeficiency syndrome (AIDS)]. / Disfunción vesicouretral en el síndrome de inmunodeficiencia adquirida (SIDA).

OBJECTIVES: Ten patients with AIDS and voiding disorders were assessed to determine the most common type of lower urinary tract dysfunction and its possible usefulness in detecting neurological disease. METHODS: A complete urodynamic evaluation was performed. RESULTS: The most common symptom was urge incontinence and the most common urodynamic finding was detrusor-external sphincter dyssynergia. Of the 5 patients found to have a neurological disorder, only 3 had demonstrable functional disorder of the lower urinary tract (2 patients had detrusor hyperreflexia: one of them had a history of encephalopathy from HIV and the other patient had polyneuritis; the third patient had myelitis and a urodynamically diagnosed sympathetic decentration. CONCLUSIONS: Knowing the functional disorders of patients with AIDS can avoid complications and improve patient quality of life. Furthermore, it can be useful in detecting an existing neurological lesion or one that may develop in the future.

[Leiomyosarcoma within a bladder diverticulum]. / Leiomiosarcoma en el seno de un divertículo vesical.

Sarcomas are a rare entity among malignant tumours of the bladder. This paper presents the case of a male patient with leiomyosarcoma within a vesical diverticulum. The approach undertaken was diverticulectomy and, since the tumour was limited to the diverticulum and no metastatic disease was present, no other adjuvant therapy was considered.

[Renal metastasis from breast carcinoma: a new case and review of the literature]. / Metástasis renal de un carcinoma de mama: un nuevo caso y revisión de la literatura.

OBJECTIVES: Breast carcinoma is the most common malignant tumor in the female. A vast majority of the cases present metastasis at the time of diagnosis. A case of breast carcinoma metastatic to the kidney is described to emphasize that in the presence of a renal mass, a secondary or metastatic tumor should be suspected. The literature is briefly reviewed. METHODS: We report on the diagnosis and treatment of an expanding left renal mass in a female patient with a previous history of multiorgan tumors (ovarian, breast and small bowel) or different histological types that had been diagnosed and treated at different periods. RESULTS: Following radical nephrectomy, analysis of the surgical specimen disclosed a metastatic tumor from breast carcinoma. No subsequent treatment was required and the patient is well 6 months postoperatively. CONCLUSIONS: Metastasis from a primary tumor must be suspected in patients with a previous history of tumor presenting with a renal mass. Renal metastasis presents in the advanced stages of tumor dissemination. Treatment depends on patient general condition and the stage of the primary and metastatic tumors.

[Obstructive uropathy as a complication of aortic disease and reconstructive peripheral vascular surgery: report of 4 cases and review of the literature]. / Uropatía obstructiva como complicación de la patología aórtica y de la cirugía reconstructiva vascular periférica: presentación de 4 casos y revisión de la literatura.

OBJECTIVES: Ureteral injury can be a complication of peripheral vascular reconstructive surgery or aneurysm of the abdominal aorta. The present study analyses 4 cases of obstructive uropathy; 3 following peripheral vascular reconstructive surgery and 1 from aneurysm of the abdominal aorta. METHODS: All 4 patients were prospectively evaluated. RESULTS: Both renal units were compromised in all 4 cases. The initial management consisted of internal urinary diversion with a double J catheter. Ureterolysis was performed in one case of unresolved uropathy secondary to prior bypass surgery. One case with uropathy due to infection of the vascular prosthetic graft required graft replacement. CONCLUSIONS: The risk of ureteral injury is likely to be seen more often due to the increasing number of operations on the vascular tree and enhanced survival of patients with aortic aneurysm. Prevention of the foregoing complication includes doing US and/or IVP early postoperatively and in the first 4 months following surgery. Patient management is initially conservative.