Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units.

BACKGROUND: Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate. AIM: To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach. METHODS: A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative. RESULTS: The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%. CONCLUSION: Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

Prevalence, risk factors and evolution of diabetes mellitus after treatment in primary aldosteronism. Results from the SPAIN-ALDO registry.

PURPOSE: To evaluate the prevalence, risk factors and evolution of diabetes mellitus (DM) after targeted treatment in patients with primary aldosteronism (PA). METHODS: A retrospective multicenter study of PA patients in follow-up at 27 Spanish tertiary hospitals (SPAIN-ALDO Register). RESULTS: Overall, 646 patients with PA were included. At diagnosis, 21.2% (n = 137) had DM and 67% of them had HbA1c levels < 7%. In multivariate analysis, family history of DM (OR 4.00 [1.68-9.53]), the coexistence of dyslipidemia (OR 3.57 [1.51-8.43]) and advanced age (OR 1.04 per year of increase [1.00-1.09]) were identified as independent predictive factors of DM. Diabetic patients were on beta blockers (46.7% (n = 64) vs. 27.5% (n = 140), P < 0.001) and diuretics (51.1% (n = 70) vs. 33.2% (n = 169), p < 0.001) more frequently than non-diabetics. After a median follow-up of 22 months [IQR 7.5-63.0], 6.9% of patients developed DM, with no difference between those undergoing adrenalectomy and those treated medically (HR 1.07 [0.49-2.36], p = 0.866). There was also no significant difference in the evolution of glycemic control between DM patients who underwent surgery and those medically treated (p > 0.05). CONCLUSION: DM affects about one quarter of patients with PA and the risk factors for its development are common to those of the general population. Medical and surgical treatment provides similar benefit in glycemic control in patients with PA and DM.

Is the emergence of fungal resistance to medical triazoles related to their use in the agroecosystems? A mini review

Abstract Triazole fungicides are used broadly for the control of infectious diseases of both humans and plants. The surge in resistance to triazoles among pathogenic populations is an emergent issue both in agriculture and medicine. The non-rational use of fungicides with site-specific modes of action, such as the triazoles, may increase the risk of antifungal resistance development. In the medical field, the surge of resistant fungal isolates has been related to the intensive and recurrent therapeutic use of a limited number of triazoles for the treatment and prophylaxis of many mycoses. Similarities in the mode of action of triazole fungicides used in these two fields may lead to cross-resistance, thus expanding the spectrum of resistance to multiple fungicides and contributing to the perpetuation of resistant strains in the environment. The emergence of fungicide-resistant isolates of human pathogens has been related to the exposure to fungicides used in agroecosystems. Examples include species of cosmopolitan occurrence, such as Fusarium and Aspergillus, which cause diseases in both plants and humans. This review summarizes the information about the most important triazole fungicides that are largely used in human clinical therapy and agriculture. We aim to discuss the issues related to fungicide resistance and the recommended strategies for preventing the emergence of triazole-resistant fungal populations capable of spreading across environments.

Is the emergence of fungal resistance to medical triazoles related to their use in the agroecosystems? A mini review.

Triazole fungicides are used broadly for the control of infectious diseases of both humans and plants. The surge in resistance to triazoles among pathogenic populations is an emergent issue both in agriculture and medicine. The non-rational use of fungicides with site-specific modes of action, such as the triazoles, may increase the risk of antifungal resistance development. In the medical field, the surge of resistant fungal isolates has been related to the intensive and recurrent therapeutic use of a limited number of triazoles for the treatment and prophylaxis of many mycoses. Similarities in the mode of action of triazole fungicides used in these two fields may lead to cross-resistance, thus expanding the spectrum of resistance to multiple fungicides and contributing to the perpetuation of resistant strains in the environment. The emergence of fungicide-resistant isolates of human pathogens has been related to the exposure to fungicides used in agroecosystems. Examples include species of cosmopolitan occurrence, such as Fusarium and Aspergillus, which cause diseases in both plants and humans. This review summarizes the information about the most important triazole fungicides that are largely used in human clinical therapy and agriculture. We aim to discuss the issues related to fungicide resistance and the recommended strategies for preventing the emergence of triazole-resistant fungal populations capable of spreading across environments.

Search for solar axions by the CERN axion solar telescope with 3He buffer gas: closing the hot dark matter gap.

The CERN Axion Solar Telescope has finished its search for solar axions with (3)He buffer gas, covering the search range 0.64 eV ≲ ma ≲ 1.17 eV. This closes the gap to the cosmological hot dark matter limit and actually overlaps with it. From the absence of excess x rays when the magnet was pointing to the Sun we set a typical upper limit on the axion-photon coupling of gaγ ≲ 3.3 × 10(-10) GeV(-1) at 95% C.L., with the exact value depending on the pressure setting. Future direct solar axion searches will focus on increasing the sensitivity to smaller values of gaγ, for example by the currently discussed next generation helioscope International AXion Observatory.

Assessment of venous thrombus time of progression by gray-scale median analysis.

AIM: To determine if gray-scale median (GSM) analysis could differentiate acute and recent deep venous thrombosis (DVT). METHODS: Patients submitted to vascular ultrasound examination of lower extremities due to suspected DVT were evaluated. Patients with acute or recent femoropopliteal DVT were included, whereas those without DVT, with chronic or isolated calf DVT were excluded. Time of onset of DVT symptoms was recorded. A transverse image of the thrombosed vein and adjacent artery was obtained. Two sonographers determined a subjective impression of thrombus time of progression and classified it as acute or recent. Thrombus GSM was calculated with a software. ROC curve was used to determine GSM cut-off points. Fischer's exact and Student´s t tests were also used. P<0.05 indicated statistical significance. RESULTS: 128 veins of 63 extremities were studied. Thrombus GSM correlated with time of onset of DVT symptoms (P=0.005) and with subjective evaluation of thrombus time of progression (P<0.001). When DVT symptoms had begun up to two weeks before and thrombus was classified as acute, GSM was lower. Area under ROC curve for thrombus GSM was 0.76 (P<0.001). GSM 17.90, 23.03, and 40.02 cut-off points differentiated between acute and recent thrombi with 35.59% sensitivity and 91.30% specificity, 59.32% sensitivity and 84.06% specificity, 91.53% sensitivity and 31.88% specificity, respectively. CONCLUSION: GSM was a reliable tool for objectively differentiating acute and recent DVT in most thrombus images. GSM 17.90 and 40.02 cut-off points showed high specificity and high sensitivity, respectively, for acute and recent DVT differentiation. In 17.90 to 40.02 interval, GSM cut-off point that best distinguished acute from recent DVT was 23.03.

Search for sub-eV mass solar axions by the CERN Axion Solar Telescope with 3He buffer gas.

The CERN Axion Solar Telescope (CAST) has extended its search for solar axions by using (3)He as a buffer gas. At T=1.8 K this allows for larger pressure settings and hence sensitivity to higher axion masses than our previous measurements with (4)He. With about 1 h of data taking at each of 252 different pressure settings we have scanned the axion mass range 0.39 eV≲m(a)≲0.64 eV. From the absence of excess x rays when the magnet was pointing to the Sun we set a typical upper limit on the axion-photon coupling of g(aγ)≲2.3×10(-10) GeV(-1) at 95% C.L., the exact value depending on the pressure setting. Kim-Shifman-Vainshtein-Zakharov axions are excluded at the upper end of our mass range, the first time ever for any solar axion search. In the future we will extend our search to m(a)≲1.15 eV, comfortably overlapping with cosmological hot dark matter bounds.

Síndrome de túnel carpiano. Estudio prospectivo pre y posquirúrgico / Carpal tunnel syndrome. Pre and post-operative prospective study

Introducción: El síndrome de túnel carpiano (STC) es la neuropatía periférica por atrapamiento más frecuente. En este estudio se valora la evolución de los parámetros clínicos y electrofisiológicos a partir del primer mes tras la cirugía de descompresión. Material y método: Estudio prospectivo en el que se incluyen 23 pacientes diagnosticados de STC. Se realiza anamnesis, exploración física y estudio electrofisiológico en la situación prequirúrgica, al mes de la cirugía de descompresión y a los 3 meses de ésta. Se comparan los resultados. Resultados: Se encuentra mejoría significativa (p<0,05) en la sensación parestésica y de dolor, en la fuerza muscular y en los parámetros electrofisiológicos de amplitud de potencial sensitivo, latencia distal sensitiva y latencia distal motora para el nervio mediano. Se obtienen rectas de regresión lineal para estos 3 últimos parámetros. Conclusiones: Se observa mejoría de algunos de los parámetros clínicos y electromiográficos tras la cirugía de descompresión del STC. Se obtienen ecuaciones de regresión lineal que permitirían conocer el grado de mejora esperable para estos parámetros en los primeros tiempos posquirúrgicos (AU)

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy. Clinical and electrophysiological examinations were conducted 1 and 3 months after surgical descompression. Material and methods: We evaluated, by means of a prospective study, the results of carpal tunnel release both clinically and electrophysiologically in 23 patients with CTS. Physical examination, electromyography and nerve conduction tests were performed pre and post-operatively (1 and 3 months after operation). We compared the results. Results: Statistically significant differences were found between preoperative and follow-up paresthesia, pain and muscle strength parameters and EMG values of motor distal latency, sensorial distal latency and sensorial latency amplitudes (p<0.05). Regression lines were obtained for these EMG parameters. Conclusions: Some of the clinical and electromyographic parameters improve after carpal tunnel release. Regression lines have been obtained and would be useful for knowing the improvement in these parameters for the first months after surgery (AU)

[What is important for the family of patients in the intensive care unit?]. / Qué es importante para los familiares de los pacientes de una unidad de cuidados intensivos.

The abundant bibliography shows us that the family plays a fundamental paper in the recovery of the hospitalized patients, and the patients in the intensive care units (ICU) are no exception. Several authors have demonstrated that a stress-free and calm setting helps in the care process. Thus, the family needs must be considered to improve their well-being. In this way, their attitude will help in the patient's recovery. Health care personnel must be aware of these needs and make up for their deficit as far as possible. The first study that evaluated this question used the CCFNI questionnaire (Critical Care Family Needs Inventory) that measures the degree of importance given by the relatives to the needs of safety, support, information, comfort and proximity. This study has aimed to detect the degree of importance given by the relatives of the patients in the ICU of the Hospital Dr. Josep Trueta of Girona, using the CCFNI questionnaire. All the relatives of the patients in said unit during the autumn of the year 2003 were interviewed and the needs considered to be most important were compared with the sociodemographic variables of the relatives. The total sample was made up of the 132 people interviewed. The need considered to be most important was safety with 50.3% followed by need for support with 47.2%. In the results, some differences were observed depending according to age and studies of those surveyed and according to the diagnosis and the origin of the hospitalization. The collected data did not differ with the reviewed bibliography. All the study was very valuable for the health care professionals of the unit and was taken into account to improve the deficiencies of the ICU of the hospital of Girona.

Qué es importante para los familiares de los pacientes de una Unidad de Cuidados Intensivos / What is important for the family of patients in the Intensive Care Unit?

La abundante bibliografía nos demuestra que la familia tiene un papel fundamental en la recuperación de los enfermos hospitalizados, y los pacientes de las Unidades de Cuidados Intensivos (UCI) no son una excepción. Varios autores han demostrado que un ambiente desangustiado y tranquilo ayuda en el proceso de cuidado. Por esto, es necesario plantearse las necesidades de las familias para mejorar su bienestar, de esta forma su actitud ayudará en la recuperación del enfermo. El personal asistencial tiene que conocer dichas necesidades y suplir el déficit en la medida posible. El primer estudio que valora esta cuestión utilizó el cuestionario CCFNI (Critical Care Family Needs Inventory), que mide el grado de importancia que los familiares otorgan a las necesidades de seguridad, apoyo, información, comodidad y proximidad. El objetivo de este estudio fue detectar el grado de importancia que dan los familiares de los pacientes ingresados en la UCI del Hospital Dr. Josep Trueta de Girona, empleando el cuestionario CCFNI. Se entrevistó a todos los familiares de los pacientes ingresados en la UCI del hospital durante el otoño del año 2003 y se compararon las necesidades consideradas más importantes con las variables sociodemográficas de los familiares. La muestra total fue 132 personas entrevistadas. La necesidad considerada más importante fue la seguridad con un 50,3%, seguida de la necesidad de apoyo con un 47,2%. En los resultados se observaron algunas diferencias dependiendo de la edad y estudios del encuestado y según el diagnóstico y procedencia del ingreso. Los datos obtenidos no discrepaban con la bibliografía revisada. Todo el estudio fue muy valioso para los profesionales asistenciales de la unidad y se tuvieron en cuenta para mejorar las deficiencias de la UCI del hospital de Girona

The abundant bibliography shows us that the family plays a fundamental paper in the recovery of the hospitalized patients, and the patients in the intensive care units (ICU) are no exception. Several authors have demonstrated that a stress-free and calm setting helps in the care process. Thus, the family needs must be considered to improve their well-being. In this way, their attitude will help in the patient's recovery. Health care personnel must be aware of these needs and make up for their deficit as far as possible. The first study that evaluated this question used the CCFNI questionnaire (Critical Care Family Needs Inventory) that measures the degree of importance given by the relatives to the needs of safety, support, information, comfort and proximity. This study has aimed to detect the degree of importance given by the relatives of the patients in the ICU of the Hospital Dr. Josep Trueta of Girona, using the CCFNI questionnaire. All the relatives of the patients in said unit during the autumn of the year 2003 were interviewed and the needs considered to be most important were compared with the sociodemographic variables of the relatives. The total sample was made up of the 132 people interviewed. The need considered to be most important was safety with 50.3% followed by need for support with 47.2%. In the results, some differences were observed depending according to age and studies of those surveyed and according to the diagnosis and the origin of the hospitalization. The collected data did not differ with the reviewed bibliography. All the study was very valuable for the health care professionals of the unit and was taken into account to improve the deficiencies of the ICU of the hospital of Girona

Acute haemodynamic effects of a hypertonic saline/dextran solution in stable patients with severe sepsis.

OBJECTIVE: To study the haemodynamic effects of a hypertonic saline/dextran solution compared with a normal saline solution in patients with severe sepsis. DESIGN: Prospective double blind and control-randomised study. SETTING: Adult intensive care unit in a university hospital. PATIENTS: Twenty-nine patients with sepsis with a pulmonary artery occlusion pressure (PAOP) lower than 12 mmHg. INTERVENTIONS: Patients were randomised to receive 250 ml of blinded solutions of either normal saline (SS group, n=16) or hypertonic saline (NaCl 7.5%)/dextran 70 8% (HSS group, n=13) solutions. MEASUREMENTS AND RESULTS: Haemodynamic, blood gas, and sodium data were collected at the following time points: baseline, 30 min, 60 min, 120 min, and 180 min. PAOP was higher in the HSS group at 30 min (10.7+/-3.2 mmHg vs 6.8+/-3.2 mmHg) and 60 min (10.3+/-3 mmHg vs 7.4+/-2.9 mmHg); P<0.05. The cardiac index increased in the HSS group and it was greater than the SS group at 30 min (6.5+/-4.7 l min(-1) m(-2) vs 3.8+/-3.4 l min(-1) m(-2)), 60 min (4.9+/-4.5 l min(-1) m(-2) vs 3.7+/-3.3 l min(-1) m(-2)), and 120 min (5.0+/-4.3 l min(-1) m(-2) vs 4.1+/-3.4 l min(-1) m(-2)); P<0.05. The stroke volume index followed a comparable course and it was higher at 30 min [53.6(39.2-62.8) ml m(-2) vs 35.6(31.2-49.2) ml m(-2)] and 60 min [46.8(39.7-56.6) ml m(-2) vs 33.9(32.2-47.7) ml m(-2)]; P<0.05. Systemic vascular resistance decreased in the HSS group and became significantly lower at 30 min (824+/-277 dyne s(-1) cm(-5) m(-2) vs 1139+/-245 dyne s(-1) cm(-5) m(-2)), 60 min (921+/-256 dyne s(-1) cm(-5) m(-2) vs 1246+/-308 dyne s(-1) cm(-5) m(-2)), and 120 min (925+/-226 dyne s(-1) cm(-5) m(-2) vs 1269+/-494 dyne s(-1) cm(-5) m(-2)). Sodium levels increased in the HSS group (P=0.056) and were higher than in the SS group at 30 min (145+/-3 mEq l(-1)vs 137+/-7 mEq l(-1)), 60 min (143+/-4 mEq l(-1) vs 136+/-7 mEq l(-1)), 120 (142+/-5 mEq l(-1)vs 136+/-7 mEq l(-1)), and 180 min (142+/-5 mEq l(-1) vs 136+/-8 mEq l(-1)). CONCLUSION: Hypertonic saline/dextran solution may improve cardiovascular performance in severe sepsis without significant side effects. The haemodynamic effect appears related mainly to a volume effect.

[Pacinian neurofibroma of the vulva]. / Neurofibroma pacciniano de la vulva.

OBJECTIVE: To report on a rare case of Pacinian neurofibroma of the vulva. METHODS: A 27-year-old patient who presented with a vulvar tumor is described. Patient evaluation showed no other remarkable findings. RESULTS: The nodule was resected without difficulty. The histopathological analysis-demonstrated Pacinian neurofibroma with abundant concentric laminar structures. The immunohistochemical (CD34+), ultrastructural and histological analyses showed perineural cells. No signs of neurofibromatosis were found. CONCLUSIONS: Pacinian neurofibroma may present in the vulva and could probably arise from the so-called perineural fibroblasts.

Síndrome de discinesia ciliar primaria / Primary ciliary dyskinesis syndrome

El síndrome de discinesia ciliar primaria (SDCP) y su variante el Síndrome de Kartagener, son una causa infrecuente de patología neumológica recurrente en el niño. El diagnóstico se basa en la sospecha clínica ante un cuadro de sinusitis y/o neumonías recurrentes, confirmándose el mismo mediante el estudio del aclaramiento mucociliar y la biopsia nasal. Presentamos 3 casos de SDCP y S. de Kartagener en los cuales el diagnóstico de sospecha se confirmó mediante la biopsia nasal, la cual, realizada con la técnica adecuada, es rápida, inocua y de fácil realización (AU)

[An ileal ulcer and diaphragm-type colonic stenosis due to diclofenac]. / Ulcera ileal y estenosis colónica tipo diafragma por diclofenaco.

Nonsteroidal anti-inflammatory drugs (NSAID) are used extensively in the general population. It's well known the adverse effects of NSAID over the upper gastrointestinal tract and small intestine. Enteric-coated and slow release preparations were created in order to prevent those effects. We describe a woman case who took diclofenac for many years and developed both ileal ulceration and diaphragm-like colonic structure. Lesions in lower gastrointestinal tract were infrequent but severe; the lesion were seen on colonoscopy but not on barium studies; the physiopathology of these lesions remains uncertain; and the most efficacy attitude is the suppression of diclofenac.

[Chronic total occlusion of the left main coronary artery]. / Oclusión crónica total del tronco común de la coronaria izquierda.

Total chronic occlusion of the left main coronary artery is a rare angiographic finding in a catheterization laboratory. After reviewing the coronary angiographies performed in our laboratory between 1986 to 1995, we found a prevalence of 0.04%. These patients presented unspecific symptoms similar to other kinds of coronary artery disease. In all cases, the right coronary artery was dominant with extensive collateral circulation to the left coronary artery. Ventricular function was normal in 50% of the cases. Probably, in these unusual cases, the best therapeutic approach is surgical revascularization.

[Leiomyosarcoma of the testis]. / Léiomyosarcome du testicule.

We present the clinical case of a patient with testicular leiomyosarcoma, the symptoms of which were a palpable mass and a frank inguinoscrotal discomfort. The reason for this paper is the extreme rarity of the condition and the differential diagnosis by all expansive inguinoscrotal tumors. Considerations are made on further examinations that may be carried out, and treatment options are discussed. Complete remission is present 2 years after onset of the disease.

[Arterial hypertension in the Baix Ebre region (Tarragona)]. / La hipertensión arterial en la comarca del Baix Ebre (Tarragona).

The results of a cross-sectional study for the evaluation of the prevalence of hypertension in the Baix Ebre region (Tarragona) are reported. 628 individuals from a randomly selected sample of 670 gave their consent to participate. The study was based on interview and examination at the patients home after getting an appointment by post. The prevalence of hypertension was 31.84 +/- 3.64%, and that of borderline hypertension 16.56 +/- 2.97%. Only 57% of hypertensives were previously known as such, and only 18.5% of these were being correctly treated. There was a significant association of hypertension with age (basically systolic blood pressure for women); also with alcohol intake, obesity and family history of hypertension or cardiovascular disease. There was no significant correlation with sex, residence in rural or urban areas, emigration, marital status, occupational status, social and professional level, education, or with the coexistence of hypertension in the spouse. The high prevalence of hypertension was a remarkable finding, consistent with its recognized importance as a first rate health problem.

[Chronic cor pulmonale due to granulomatous and obliterating pulmonary arteritis caused by schistosomiasis]. / Chronisches Cor pulmonale durch granulomatöse und obliterierende pulmonale Arteriitis bei Schistosomiasis.

Among 3,125 autopsies undertaken at the Department of Pathology of the "Américo Boavida" Hospital in Luanda, from January 1976 to March 1987, we recorded four cases of children with schistosomiasis. Macroscopically, we observed Symmers type periportal fibrosis and chronic cor pulmonale secondary to schistosomiasis of liver and spleen. Histological examination of the lungs revealed granulomatous arteritis, obliterating segmental endarteritis and multiple schistosoma granulomas in the parenchyma. Pulmonary hypertension had caused secondary changes to arteries, such as subendothelial fibrosis and hypertrophy of the media.