Decúbito prono prolongado: una estrategia no ventilatoria en neumonía grave por SARS-CoV-2 / Prono position: a non-ventilatory strategy in patients with severe pneumonia due to SARS-CoV-2 / Posição prona prolongada: uma estratégia não ventilatória em pneumonia grave devido a SARS-CoV-2

Resumen: Introducción: La neumonía grave por SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) ocasiona hipoxemia severa, por lo anterior, las guías para el manejo de pacientes adultos críticamente enfermos con COVID-19 recomiendan el uso de la posición decúbito prono para mejorar la oxigenación. Material y métodos: Estudio de cohorte, prospectivo, descriptivo y analítico. Pacientes ingresados a la unidad de cuidados intensivos en el periodo comprendido entre el 18 de abril de 2020 y el 18 de agosto de 2021 con ventilación mecánica invasiva (VMI) secundaria a neumonía grave por SARS-CoV-2 confirmados. Resultados: En el periodo comprendido se incluyeron 110 pacientes que cumplieron con los criterios de inclusión. Del total, 88 pacientes se incluyeron en el grupo de mejoría sostenida al retiro del prono y 22 en el grupo de mejoría no sostenida al retiro del prono. Se observó que la disminución del porcentaje de la PaO2/FiO2 al retiro del prono es útil para predecir mortalidad con ABC de 0.740 con IC95% de (0.646-0.834) y p = 0.001. Conclusión: La disminución > 50% de la PaO2/FiO2 al retiro de la posición decúbito prono prolongado o mejoría no sostenida es un predictor de mortalidad en los pacientes con neumonía grave por SARS-CoV-2.

Abstract: Introduction: Severe pneumonia due to SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) causes severe hypoxemia, therefore, the guidelines for the management of critically ill adult patients with COVID-19 recommend the use of the prone position to improve oxygenation. Material and methods: A prospective, descriptive and analytical cohort study. Patients admitted to the intensive care unit in the period from April 18, 2020 to August 18, 2021 with confirmed IMV secondary to severe SARS-CoV-2 pneumonia. Results: In the period covered, 110 patients who met the inclusion criteria were included. Of the total, 88 patients were included in the group with sustained improvement at prone withdrawal and 22 in the group with non-sustained improvement at prone withdrawal. It was observed that the% Decrease in PaO2/FiO2 upon prone removal is useful to predict mortality with AUC of 0.740 with 95% CI of (0.646-0.834) and p = 0.001. Conclusion: A > 50% decrease in PaO2/FiO2 upon removal from prolonged prone position or unsustained improvement is a predictor of mortality in patients with severe SARS-CoV-2 pneumonia.

Resumo: Introdução: A pneumonia grave por SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) causa hipoxemia grave, portanto, as diretrizes para o manejo de pacientes adultos criticamente doentes com COVID-19 recomendam o uso da posição prona para melhorar a oxigenação. Material e métodos: Estudo de coorte, prospectivo, descritivo e analítico. Pacientes admitidos na unidade de terapia intensiva no período entre 18 de abril de 2020 e 18 de agosto de 2021 com VMI secundária a pneumonia grave por SARS-CoV-2 confirmadas. Resultados: No período abrangido, incluíram-se 110 pacientes que atenderam aos critérios de inclusão. Do total, 88 pacientes foram incluídos no grupo melhora sustentada na retirada da posição prona e 22 no grupo melhora não sustentada na retirada da posição prona. Observou-se que a % de diminuição da PaO2/FiO2 na retirada da pronação é útil para predizer mortalidade com ABC de 0.740 com IC de 95% de (0.646-0.834) e p = 0.001. Conclusão: Uma diminuição > 50% na PaO2/FiO2 após a retirada da posição prona prolongada ou melhora não sustentada é um preditor de mortalidade em pacientes com pneumonia grave por SARS-CoV-2.

Quality improvement programs and the professional nursing practice environment: an integrative review / Programas de mejoría de calidad y el ambiente de práctica profesional de enfermería: revisión integrativa / Programas de melhoria de qualidade e o ambiente de prática profissional de enfermagem: revisão integrativa

ABSTRACT Objectives: to analyze the knowledge produced regarding the practice environment in hospitals with quality improvement programs. Methods: integrative literature review performed in the Latin American and Caribbean Literature in Health Sciences databases, US National Library of Medicine/National Institutes of Health, Web of Science, Scopus and CINAHL, consisting in 10 articles. Results: data were presented and discussed using categories: Measures for the professional nursing practice environment; Hospital accreditation as an improvement program; Nursing autonomy, interpersonal relationship between nurse and doctor and the nurse as a manager and leader. Final Considerations: it was possible to analyze that the influence of quality improvement programs can be considered as favorable in the professional nursing practice environment. The survey also brings contributions to administration in implementing strategies aiming at continuous improvement in the environment characteristics.

RESUMEN Objetivos: analizar el conocimiento producido cuanto al ambiente de práctica en hospitales que poseen programas de mejoría de la calidad. Métodos: revisión integrativa de la literatura realizada en las bases de datos de la Literatura Latinoamericana y del Caribe en Ciencias de la Salud, US National Library of Medicine/National Institutes of Health, Web of Science, Scopus y CINAHL, comprendiendo 10 artículos. Resultados: los datos han presentados y discutidos usándose categorías: Medidas para el ambiente de práctica profesional de enfermería; la Acreditación Hospitalaria como programa de mejoría; Autonomía de la enfermería, relación interpersonal entre enfermería y médico y enfermero como gestor y líder. Consideraciones Finales: ha sido posible analizar que la influencia de programas de mejoría de la calidad puede considerarse como favorable sobre el ambiente de práctica profesional de enfermería. También aporta contribuciones para la gestión en la implantación de estrategias objetivando a la mejoría continua de las características del ambiente.

RESUMO Objetivos: analisar o conhecimento produzido quanto ao ambiente de prática em hospitais que possuem programas de melhoria da qualidade. Métodos: revisão integrativa da literatura realizada nas bases de dados Literatura Latino-Americana e do Caribe em Ciências da Saúde, US National Library of Medicine/National Institutes of Health, Web of Science, Scopus e CINAHL, compreendendo 10 artigos. Resultados: os dados foram apresentados e discutidos usando-se categorias: Medidas para o ambiente de prática profissional de enfermagem; a Acreditação Hospitalar como programa de melhoria; Autonomia da enfermagem, relacionamento interpessoal entre enfermagem e médico e enfermeiro enquanto gestor e líder. Considerações Finais: foi possível analisar que a influência de programas de melhoria da qualidade pode ser considerada como favorável sobre o ambiente de prática profissional de enfermagem. O estudo também traz contribuições para a gestão na implantação de estratégias visando à melhoria contínua das características do ambiente.

Maternal mortality / Mortalidad materna

The maternal mortality ratio (MMR) for each population is an indicator of medical and surgical quality control. The World Health Organization has committed to decreasing maternal mortality worldwide. Access to care remains an important facet of improving overall health of populations. Quality control and excellent communications among health care providers is equally important. Standardization of obstetric emergency protocols will further decrease maternal mortality.

La razón de mortalidad materna (RMM) representa un control de calidad médico y quirúrgico para cada población. La Organización Mundial de la Salud se ha propuesto disminuir la mortalidad maternal en el mundo. El acceso al cuidado médico sigue siendo una faceta importante para mejorar la salud poblacional. Es igualmente importante el control de la calidad y la excelente comunicación entre los profesionales de la salud. La estandarización de los protocolos de emergencia obstétrica permitirá una mayor disminución de la mortalidad materna.

[Association between visual improvement after photocoagulation and the use of angiotensin converting enzyme inhibitors in diabetic macular oedema]. / Asociación entre la mejoría visual y el uso de inhibidores de la enzima convertidora de angiotensina, en edema macular diabético.

BACKGROUND: Angiotensin converting enzyme inhibitors are effective in delaying the progression of diabetic retinopathy. It is unknown if their use is associated with a better visual outcome in patients with diabetic macular oedema. MATERIAL AND METHODS: A non-experimental, comparative, longitudinal and retrospective study was performed on patients with diabetic macular oedema treated by focal photocoagulation, and with systemic arterial hypertension treated with angiotensin converting enzyme inhibitors (Group 1), and without hypertension (Group 2). The dependent variable was the proportion with visual improvement, operatively defined as the gain of one or more lines of vision three weeks after photocoagulation. The independent variable was the use of angiotensin converting enzyme inhibitors. The proportion of eyes with visual improvement after treatment was compared between groups using the Chi squared (χ(2)) test. RESULTS: A total of 33 eyes (51.6%) were assigned to group 1, and 31 (48.2%), to group 2. The mean of visual acuity improved after three weeks, compared with baseline (p=0.002). The proportion of eyes with visual improvement did not differ between patients treated with angiotensin converting enzyme inhibitors (45.5%) and those that did not use them (51.6%, p=0.4). CONCLUSIONS: There was no statistical difference in the proportion of eyes with visual improvement between patients treated with angiotensin converting enzyme inhibitors and in those where they were not used. There is no support for the inhibition of angiotensin II in addition to photocoagulation for improving the outcome in patients with diabetic macular oedema.

Impact of a Meditation Program on Pulse-Wave Velocity, C-reactive Protein and Quality of life / Impacto de un programa de meditación sobre la velocidad de onda de pulso, la proteína C-reactiva y la calidad de vida

background: Although various studies refer to the effect of meditation on blood pressure (BP), its impact on other cardiovascular clinical variables is unknown. Objective: The aim of this study was to evaluate the effects of a meditation program on pulse wave velocity (PWV), quality of life and ultrasensitive C-reactive protein (us-CRP) in patients with ischemic heart disease or chronic heart failure. Methods: This was a randomized study with two groups of patients: a meditation group (M) and an active control group (AC) with cardiovascular health education, evaluating the difference between initial and final values at 12 weeks of B P, PWV, quality of life (assessed by the SF-36 questionnaire) and us-CRP. results: Thirty-five patients were included in the M group and 35 in the AC group; mean age was 61 years and 80% were men. Both groups had similar baseline characteristics, except for higher number of smokers and triglyceride levels in the M group. At 12 weeks, no significant differences were found for ∆PWV: +0.51 (±1.40) in AC and +0.19 (±1.53) in M (p=0.37). Conversely, ∆SF-36 was +0.79 (±7.58) in AC vs. +5.40 (±9.69) (p=0.03) in M, and ∆us-PCR was +1.17 (±2.9) in AC vs. -0.69 (±0.89) in M (p=0.02). Conclusions: A meditation program did not significantly modify PWV at 12 weeks. However, patients allocated to this intervention improved their quality of life and us-PCR was significantly reduced. Larger studies are required to confirm these findings and explore the mechanisms involved in this improvement.

Clinical and Functional Outcome of Percutaneous alcohol septal ablation in Obstructive Hypertrophic Cardiomyopathy / Resultados clínicos y funcionales de la ablación septal percutánea con alcohol en la miocardiopatía hipertrófica obstructiva

background: Percutaneous septal ablation is a therapeutic option for patients with obstructive hypertrophic cardiomyopathy refrac-tory to optimal medical therapy. However, results of initial persistence and long-term safety are still controversial. Objectives: The aim of this study was to report percutaneous alcohol septal ablation technique, clinical and functional outcome, cardiovascular events and its impact on long-term follow-up. Methods: A total of 23 patients were included in the study. Functional class (FC), left ventricular outflow tract gradient before and after the procedure and long-term cardiovascular events were evaluated. results: Median follow-up was 52 months (IR 33-72). All patients were in FC III or IV prior to the procedure, under maximum tolerated medical therapy. The procedure was successful in 91% of cases, with 85% of patients currently in FC I and 15% in FC II. Baseline left ventricular outflow tract gradient decreased from 75 mmHg (95% CI 51-89) to 25 mmHg (95% CI 10-37) (p <0.003) and with Valsalva maneuver from 118 mmHg (95% CI 88-152) to 38 mmHg (95% CI 16-69) (p <0.0002), persisting in the long-term follow-up. During hospitalization, two patients presented with complete atrioventricular block requiring permanent pacemaker implantation. No cardiovascular deaths occurred during follow up. Conclusions: Alcohol septal ablation is a promising option for the treatment of a selected population with hypertrophic obstructive cardiomyopathy, generating sustained clinical and functional improvement with low incidence of events in the long-term follow up.

Mejoría mucosa endoscópica en pacientes con enfermedad inflamatoria intestinal / Endoscopic mucosal improvememt in patients with inflammatory bowel disease

La curación mucosa endoscópica en enfermedad inflamatoria intestinal se asocia con remisión clínica sostenida, reducción de hospitalizaciones y cirugía, pero lograrlo es difícil, según la literatura. Por ello evaluamos la mejoría mucosa endoscópica en nuestros pacientes. Objetivo: Evaluar la mejoría mucosa endoscópica en pacientes con enfermedad inflamatoria intestinal. Métodos: estudio multicéntrico, descriptivo, transversal. Incluyó 24 pacientes entre 17 y 73 años. Para evaluar respuesta a tratamiento se realizó colonoscopia, utilizando clasificaciones endoscópicas de Mayo para colitis ulcerosa, Score simplificado para enfermedad de Crohn y Rutgeerts para recurrencia post operatoria, considerando curación endoscópica grado 0 en todas las escalas y mejoría cuando disminuyó un grado en relación al estudio previo. Resultados: colitis ulcerosa: 12 pacientes, 10 recibían aminosalicilatos y 2 terapia biológica. De ellos, 3 tuvieron curación endoscópica y 8 mejoría. De estos, 6 recibían aminosalicilatos y 2 Infliximab. Hubo 1 paciente con aminosalicilatos sin mejoría. Enfermedad de Crohn: 12 pacientes, 7 con aminosalicilatos, 2 con biológicos, 2 con biológicos e inmunomoduladores y 1 con biológicos y aminosalicilatos. De ellos, 4 tuvieron mejoría, 6 mantuvieron igual afectación y 2 curación con aminosalicilatos. Conclusiones: Se observó un alto porcentaje (70,8%) de curación y mejoría endoscópica, asociado a adherencia y optimización del tratamiento.

Introduction: endoscopic mucosal healing in inflammatory bowel disease has been associated with sustained clinical remission and hospitalizations and surgery reduction, but it has been difficult to achieve, according to the literature. So, we decided to assess improvement in endoscopic mucosal in our inflammatory bowel disease patients. Purpose: endoscopic mucosal assess improvement in patients with inflammatory bowel disease. Methods: multicenter, descriptive and transversal. We included 24 patients with IBD between 17-73 years. Control colonoscopy was performed to evaluate the response to treatment using endoscopic Mayo Score for ulcerative colitis, Simplified Score for Crohn’s disease and postoperative recurrence was evaluated with Rutgeerts Index endoscopic healing was considered when the patient had grade 0 at all scales and improvement when they had one point less in the endoscopy scale in decreased relation to the previous study. Results: ulcerative colitis: 12 patients, 10 received aminosalicylates and 2 biological therapy. The group receiving aminosalicylates, 3 had endoscopic healing, there was endoscopic improvement in 8 of which 6 are aminosalicylates and 2 Infliximab. There was one patient with no improvement aminosalicylates. Crohn’s Disease: 12 patients, 7 with aminosalicylates, 2 biological therapy alone, 2 with biological and immunomodulatory and 1 with biological and aminosalicylates. Of which 4 had endoscopic improvement, 12 stayed the same degree of involvement and 2 with aminosalicylates was endoscopic healing. Conclusions: There was a high percentage (70.8%) of healing and endoscopic improvement associated with adherence and treatment optimization.

Estado de la provisión de cuidados nutricionales al paciente quemado. Auditoría de procesos en un Servicio de Quemados de un hospital terciario / Current status of nutritional care provision to burnt patients. Processes audit of a burnt patients department from a tertiary hospital

Justificación: La respuesta al tratamiento médico-quirúrgico del paciente quemado pudiera depender tanto de los estragos provocados por la agresión térmica, a saber las demandas metabólicas incrementadas, la aparición del Síndrome de Respuesta Inflamatoria Sistémica, y las infecciones microbianas; como de las prácticas culturales incluidas dentro de los procesos institucionales de cuidados nutricionales. Objetivo: Evaluar cómo la conducción de los procesos nutricionales de evaluación e intervención influye sobre los indicadores de la efectividad terapéutica de los Servicios de Quemados. Serie de estudio: Cuarenta y dos pacientes atendidos con una superficie corporal quemada (SCQ) > 10 por ciento, entre enero del 2001-diciembre del 2003, en el Servicio de Quemados del Hospital Clínico Quirúrgico Hermanos Ameijeiras (Ciudad La Habana, Cuba). Métodos: Los procesos nutricionales de evaluación e intervención conducidos en el paciente quemado se auditaron mediante revisión de las historias clínicas. Los procesos auditados se declararon como Completados (o no). El grado de completamiento del proceso se relacionó con las tasas de complicaciones y mortalidad, y el índice de hospitalización predicho de la SCQ. Resultados: Los procesos nutricionales de evaluación e intervención se completaron en el 49,4 por ciento y 22,6por ciento de las historias auditadas, respectivamente. El registro evolutivo del peso corporal se asoció con una menor mortalidad. La evaluación nutricional temprana y un aporte energético suficiente en lesionados con SCQ > 20 por ciento se asociaron con menores tasas de complicaciones y un mejor cumplimiento del índice de hospitalización. Conclusiones: Este trabajo constituye la primera aproximación al comportamiento del Servicio de Quemados de la institución, como antesala del diseño e implementación de un programa de mejoría continua de la calidad en la atención médica......(AU)

Rationale: Response of the burned patient to surgical medical treatment might depend not only upon the damages brought about by thermal agression, namely, increased metabolic requirements, onset of the Systemic Inflamatory Response Syndrome, and microbial infections, but also the cultural practices embedded within nutritional care institutional processes. Goal: To assess how conduction of nutritional care processes of assessment and intervention may influence therapeutical effectiveness indicators of hospital Burn Services. Study serie: Forty-two patients with a Burn Body Surface Area (BBSA) > 10 percent assisted at the Burn Service of the Hermanos Ameijeiras Clinical Surgical Hospital (La Habana, Cuba), between January 2001-December 2003. Methods: Nutritional care of assessment and intervention conducted upon the burn patient were audited after reviewing clinical charts. The audited processes were declared as Completed (or not). Completeness of the process was related to complications and mortality rates, and length of hospital stay predicted from BBSA. Results: Nutritional care processes of assessment and intervention were completed in 49.4 percent and 22.6 percent of the audited charts, respectively. Prospective recording of patient's body weight was associated with lower mortality. Early nutritional assessment and sufficient energy supply to patients with BBSA > 20percent were associated with lower complications rates and better compliance with BBSA-predicted length of stay. Conclusions: This work is the first enquiry into the behaviour of the institution's Burn Service, in anticipation of the design and implementation of a medical care Continuous Quality Improvement Program. In spite of the current state of nutritional care processes completeness, their observance might favorably influence the Service's effectiveness indicators(AU)