Variabilidad de la práctica clínica para la enfermedad pulmonar obstructiva crónica en consultas externas / Variability in clinical practice for chronic obstructive pulmonary disease in outpatient clinics

OBJETIVOS: hasta el momento no existen trabajos de auditorías clínicas que evalúen la práctica clínica en la enfermedad pulmonar obstructiva crónica (EPOC) en el ámbito de consultas externas. El presente trabajo es un primer proyecto piloto que tiene por objetivo evaluar la variabilidad de la práctica clínica para la EPOC en este ámbito asistencial. MÉTODO: proyecto piloto de auditoría de historias clínicas llevada a cabo en consultas externas de Neumología en 9 hospitales públicos de Andalucía entre octubre 2013 y septiembre 2014. El objetivo era auditar 80 casos por centro, repartidos durante los 4 trimestres del año. La información se recogió mediante cuestionario estandarizado con 182 variables. Los datos se describen con medias y rangos interhospitalarios para evaluar la variabilidad. RESULTADOS: durante el año de estudio se analizaron 621 historias. Los pacientes eran mayoritariamente hombres, en la séptima década de la vida, con un porcentaje de fumadores activos del 26,2%, un considerable número de comorbilidades y mayoritariamente del ámbito urbano. Los datos indican que la atención sanitaria es en general correcta como promedio, pero indicando áreas de mejora en algunos puntos y una considerable variabilidad entre centros con diferencias significativas (p <0,001) para los cambios intercentro de la mayoría de las variables. CONCLUSIONES: la atención sanitaria al paciente con EPOC en consultas externas de Neumología en Andalucía muestra una considerable variabilidad que probablemente no pueda ser explicada sólo por la condición clínica del paciente. Estudios futuros deberán dilucidar qué factores inciden en esta variabilidad

OBJECTIVES: To date, there have been no clinical audits that evaluate clinical practice for chronic obstructive pulmonary disease (COPD) in outpatient clinics. This study is the first pilot project that aims to evaluate the variability in clinical practice for COPD in this healthcare setting. METHOD: A medical history audit pilot project carried out in outpatient pulmonology clinics in 9 public hospitals in Andalusia from October 2013 to September 2014. The objective was to audit 80 cases per center, distributed across the 4 quarters of the year. Information was collected using a standardized questionnaire with 182 variables. Data is described as averages and inter-hospital ranges to evaluate variability. RESULTS: 621 histories were analyzed during the year of the study. Patients were primarily male, in the seventh decade of life, 26.2% were active smokers, there were a considerable number of comorbidities and subjects lived in mainly urban areas. Data indicates that healthcare is generally appropriate on average, but there are areas of improvement in some points and there is a considerable variability between centers with significant differences (p <0.001) for inter-center changes for the majority of variables. CONCLUSIONS: Healthcare for patients with COPD in outpatient pulmonology clinics in Andalusia shows considerable variability that likely cannot be explained solely by the patient's clinical condition. Future studies must clarify what factors come into play in this variability

Efficacy of daptomycin in the treatment of enterococcal endocarditis: a 5 year comparison with conventional therapy.

OBJECTIVES: Enterococcus spp. account for 10% of infective endocarditis (IE). Although daptomycin is a bactericidal drug with in vitro activity against Enterococcus, there is little experience of its use in IE. We analysed the effectiveness of daptomycin in the treatment of enterococcal IE (EIE). METHODS: This was a retrospective descriptive study comparing the efficacy of daptomycin versus ampicillin/ceftriaxone versus conventional antibiotic regimens (ampicillin or vancomycin ±â€Šgentamicin) in EIE. RESULTS: From January 2007 to December 2011, 6 patients with EIE treated with daptomycin monotherapy were compared with 21 patients treated with ampicillin/ceftriaxone and 5 patients treated with ampicillin or vancomycin ±â€Šgentamicin. The three groups had similar epidemiological and clinical characteristics. Daptomycin indications were allergy to ß-lactams (n = 3), therapy simplification (n = 2), renal failure (n = 2) and Enterococcus faecium resistant to ampicillin/gentamicin (n = 1). Daptomycin MICs ranged from 1 to 2 mg/L and the doses were 6-10 mg/kg/day intravenously. Daptomycin patients had longer duration of bacteraemia (6 versus 1 day, P < 0.01) and greater need of therapy switch due to complications (66.7% versus 0%, P < 0.01). There were no differences regarding duration of hospital stay or mortality. CONCLUSIONS: Daptomycin-treated patients more frequently required a therapeutic change due to worse microbiological and clinical response, although mortality was not increased. Our findings do not support the use of daptomycin as single therapy in the treatment of EIE. Its role in combined strategies should be further investigated.

Kinetics of the extraction of pyrene using carbon dioxide in dense phase.

Bath extraction experiments of pyrene from two spiked soils with different textural composition (sandy, sandy-clay) were performed with near-critical and supercritical CO(2) at different pressures (7.5, 15, 20, 25 MPa) and temperatures (40, 50, 60 degrees C) in order to obtain mass transfer rate data. An empirical equation whose parameters depend on type of soil but are independent of pressure and temperature is proposed. The comparison between individual mass transfer coefficients shows that the extraction is controlled by the resistance within the particle. Effective diffusivities between 0.4 and 6.0 x 10(-10) m(2)/s are deduced.

Neumonía necrotizante por salmonella en paciente etílico / Necroting pneumonia by salmonella in abuse alcohol patient

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Failure of talc pleurodesis is associated with increased pleural fibrinolysis.

Diffuse pleural inflammation and fibrin deposition following the instillation of the sclerosing agent is considered necessary for a successful pleural symphysis. We hypothesized that an impairment in fibrin formation or an increased endopleural fibrinolysis would lead to failure of pleurodesis. To investigate changes in the pleural coagulation/fibrinolysis balance, we studied 75 consecutive patients who underwent thoracoscopy. Fifty-four of these patients with malignant pleural effusions and four with a benign recurrent effusion underwent thoracoscopic talc pleurodesis. Another four patients with malignancy and 13 with benign effusions had no talc poudrage performed and were included as a control group. Serial determinations of thrombin-antithrombin III complex (TAT), plasminogen activator inhibitor (PAI), and D-dimer were made in pleural fluid samples taken at the beginning of thoracoscopy (baseline), immediately after thoracoscopic biopsies had been done (postbiopsy), 3 h after thoracoscopy--either with talc poudrage or without--and 24 and 48 h after the procedure, as well as in cases of recurrence of effusions (farline). Successful pleurodesis was obtained in 42 of 52 patients who could be evaluated (81%), and failure was seen in 10. Strong activation of coagulation and production of PAI was observed in all groups, including the control (no talc) group. Fibrinolytic activity (as expressed by D-dimer levels) showed a clear decline 24 h after talc poudrage in patients with a good outcome of pleurodesis, as oppossed to those with bad results and to the control group, and returned to the baseline by 15 d. We conclude that increased pleural fibrinolytic activity is associated with failure of pleurodesis, despite significant inhibitory activity of PAI in all groups.

Síndrome de diarrea grave prolongada y nutrición parenteral / Syndrome of prolonged gravis diarrhea and parenteral nutrition

La diarrea grave prolongada de la infancia debe considerarse una enfermedad nutriciónal. La formas de tratamiento descriptas son la nutricional enteral a débito continuo (NEDC) y la nutrición parenteral total (NPT). Ante el fracaso de una NEDC utilizando fórmulas semielementales se impone la NPT. Se revisan en este estudio, en forma retrospectiva, trece casos de diarrea grave prolongada que requirieron NPT. Doce de ellos, luego de un tiempo en promedio de veinte dias de NPT, pudieron continuar su recuperación nutricional con NEDC. Uno falleció por complicación quirúrgica de su enfermedad. La NTP se muestra como alternativa eficaz ante el fracaso de la NEDC, en el soporte nutricional de la diarrea grave prolongada.

Síndrome de diarrea grave prolongada y nutrición parenteral / Syndrome of prolonged gravis diarrhea and parenteral nutrition

La diarrea grave prolongada de la infancia debe considerarse una enfermedad nutriciónal. La formas de tratamiento descriptas son la nutricional enteral a débito continuo (NEDC) y la nutrición parenteral total (NPT). Ante el fracaso de una NEDC utilizando fórmulas semielementales se impone la NPT. Se revisan en este estudio, en forma retrospectiva, trece casos de diarrea grave prolongada que requirieron NPT. Doce de ellos, luego de un tiempo en promedio de veinte dias de NPT, pudieron continuar su recuperación nutricional con NEDC. Uno falleció por complicación quirúrgica de su enfermedad. La NTP se muestra como alternativa eficaz ante el fracaso de la NEDC, en el soporte nutricional de la diarrea grave prolongada. (AU)

[Pulmonary aspiration puncture in the etiological diagnosis of pneumonias]. / Punción aspirado pulmonar en el diagnóstico etiológico de las neumonías.

In pneumonias, the short diagnostic results of non-invasive procedures lead frequently to use invasive techniques, among which we find pulmonary puncture aspiration (PPA). In this study, the profitability of PPA in the diagnosis of pneumonias is evaluated. One hundred and thirteen PPA were performed on 107 patients diagnosed of pneumonia. The PPA was performed with a 22-25 G needle without radioscopic control. Hemocultures were gathered in 104 cases, serological tests for productive agents of atypical pneumonia were applied in 50 cases, sputum test in 95 cases, and bronchofibroscopy with occluded telescopic brush in 25. The PPA had a specificity of 98 percent and a sensibility of 54% which rose to 73% in patients without antibiotic treatment prior to the puncture. Only 10 patients had complications with pneumothorax (9 percent) and four (3 percent) presented hemoptysic sputum. In the 53 patients with a positive PPA, knowledge of an etiological agent allowed the antibiotic treatment to be switched in 32 cases (60 percent). In addition, a decrease in the number of days of hospitalization was confirmed in the group of patients who received an etiological diagnosis while alive (p < 0.03). In conclusion, the PPA is a technique with excellent specificity, acceptable sensitivity, and a short rate of complications which allowed the treatment to be changed in 60 percent of the cases and reduced the number of days of hospitalization for patients who received a diagnosis. Thus, it constitutes a very useful technique in the etiological diagnosis of severe pulmonary infections.