Uso rutinario del Pneumonia Severity Index en el servicio de urgencias: efecto sobre los indicadores de proceso y resultado en neumonía adquirida en la comunidad

Objective

To evaluate process-of-care indicators (inappropriate hospitalisation, suitability and early antibiotic treatment) and outcome indicators (length of hospital stay, hospital readmission, ICU admission, and mortality) in the management of community-acquired pneumonia (CAP) when the SEPAR/IDSA guidelines were applied.

Patients and methods

An observational retrospective study conducted on patients diagnosed with CAP during the first semester of 2007 and 2008 (186 and 161 patients, respectively) in the emergency unit of a general hospital. Differences in the process-of-care and outcome indicators between 2007 and 2008 (with and without the Pneumonia Severity Index [PSI]) were evaluated. Moreover, the indicators were compared with those obtained in 2006 (110 patients), when the current guidelines were those of SEQ/ATS.

Results

The SEPAR/IDSA guidelines improved the following process-of-care indicators: appropriateness of treatment, unjustified hospital readmission (39.4% in 2006 vs. 8.5% in 2007 [P < .001], and 17,2% in 2008 [P = .005]), and early treatment. However, outcome indicators did not change. In 2008, a decrease in the mortality of the patients of risk classes IV-V in which the PSI had been estimated was observed in comparison with the patients in which the PSI was not estimated (2.3% vs. 28.3%; P < .001). Moreover, the mortality rate of the patients of risk classes IV-V in which the PSI had been estimated was lower than those measured using the SEQ/ATS guidelines (22.7%; P = .003).

Conclusion

SEPAR/IDSA guidelines decreased the unjustified hospital readmission. In the second year of its application an increase in the number of patients who received early treatment, and a decrease of the mortality rate of the patients of risk classes IV-V in which the PSI had been estimated, were also observed.     

Conductas sexuales de alto riesgo en hombres que tienen relaciones sexuales con hombres según tipo de pareja sexual

Objective

To identify factors associated with high risk sexual practices among men who have sex with men (MSM) in Spain.

Methods

An online survey was conducted in 2010, which included, among others, questions on HIV/STI sexual behaviours and prevention needs. Unprotected anal intercourse (UAI) with a partner of unknown or discordant HIV status in the past year was defined as a high risk sexual behaviour.

Results

Of the 13,111 participants, 49.4% had had sex with steady partners (SP) and 73.4% with non-steady partners (NSP) in the last 12 months; and the prevalence of high risk UAI was 25.4% and 29.4%, respectively. Factors associated with high risk UAI with SP were: living in a city of less than 500,000 inhabitants (OR = 1.42 < 100,000 inhabitants), being out to no-one or only a few people (OR = 1.42), and being HIV-positive with undetectable viral load among those with a high level of HIV/STI knowledge (OR = 3.18). Factors associated with high risk UAI with NSP were mainly: having a higher number of sexual partners (OR = 4.31 > 50 partners), having used drugs for sex (OR = 1.33), and at parties (OR = 1.19), having a medium (OR = 1.82) or low (OR = 1.33) level of HIV/STI knowledge, and being HIV-positive (OR = 1.56).

Conclusions

Among MSM, the prevalence of high risk sexual practices is high with both SP and NSP. Factors associated with high risk UAI vary by type of sexual partner (e.g., having HIV with an undetectable viral load). These must be taken into account when planning strategies for primary and secondary prevention.     

Baja prevalencia de resistencias primarias frente al virus de la hepatitis B en el sur de España

Introduction

To know the prevalence of primary resistance in chronic hepatitis B naïve patients is essential to decide on the need of routine laboratory testing.

Patients and methods

The genetic sequence of the HBV polymerase from 105 naïve patients was analysed.

Results

rtV173L, a lamivudine compensatory mutation, was detected in two patients (1.9%), rtI233V in one patient, and another one carried the sG145R vaccine escape mutation.

Conclusion

Our study shows that studying HBV resistance in naïve patients should not be recommended in the routine laboratory setting, for the time being     

Dificultades en el diagnóstico de los pacientes con enfermedad de Wilson en la práctica clínica: experiencia de 15 casos

Background

Wilson disease (WD) is an inherited disorder that causes copper (Cu) accumulation, leading to mainly liver, neurological and/or psychiatric manifestations. In the absence of some of the typical features, diagnosis of WD is difficult and is based on the combination of clinical, biochemical and genetic testing. The aim of this study was to illustrate the complexity of the approach to WD in daily clinical practice.

Methods

We retrospectively analyzed the medical records of patients with WD, including the clinical presentation, histological and biochemical findings, and follow up after treatment. We also carried out genetic testing, and the Leipzig diagnostic score was applied.

Results

We included 15 patients. Four were symptomatic, with liver (n = 1), neurological (n = 1), psychiatric (n = 1) and mixed clinical manifestations (n = 1), and 11 were presymptomatic, with elevated transaminases (n = 8) and family study (n = 3).We observed Kayser-Fleischer ring in 2 patients, both without neurologic symptoms.Ceruloplasmin ≤5 mg/dL was present in 73%, and 24-hour urinary Cu > 100 μg in 40%. Liver Cu was > 250 μg/g.d.t. in 85% of the patients. The final diagnosis of WD was given by genetic testing (ATP7B gene mutations) in 5 patients with minimal disease features, including one symptomatic patient (psychiatric symptoms). We identified 5 previously reported mutations (p.M645R, p.R827W, p.H1069Q, p.P768L and p.G869R) and 3 unpublished mutations (p.L1313R, p.I1311T and p.A1179D); the most frequent mutation was p.M645R.After treatment, biochemical parameters (transaminases, urinary cooper) and symptoms improved, except in patients with neurological and psychiatric manifestations.

Conclusions

Our series illustrates the important role of genetic testing in the diagnosis of WD. The identification of the p.M645R mutation in most of our patients should be kept in mind in the molecular analysis of the ATP7B gene in our region.     

Prevalencia de los marcadores de infección de los virus de las hepatitis en pacientes portadores del VIH en el sur de España

Objectives

To determine: (a) The prevalence of active infection by the hepatitis C virus (HCV) and hepatitis B virus (HBV) in HIV-infected patients, as well as previous exposure to hepatitis A virus (HAV), HBV and HCV. (b) The proportion of patients who have been vaccinated against HAV and/or HBV. (c) The HCV genotype distribution and the percentage of patients who have started treatment against HCV infection.

Methods

All HIV-infected patients who attended the Infectious Diseases Unit of a tertiary care hospital in Southern Spain between September 2008 and February 2009 were included in a prospective cross-sectional study.

Results

A total of 520 patients were included. Three hundred and fifty-eight (69%) patients had positive HCV antibody, while 71% of them showed detectable HCV-RNA. The HCV genotype distribution was: 153 (62%) genotype 1, 49 (20%) genotype 3, and 45 (18%) genotype 4. One hundred and thirteen (36.5%) subjects had received treatment against HCV. The prevalence of active HBV infection was 4.4%, while the exposure to HBV was 54.8%. Four hundred and thirty-seven (84%) patients had positive markers of infection of HAV. Of the patients eligible to be vaccinated, 25.6% and 22.3% patients were vaccinated against HAV and HBV, respectively.

Conclusions

The current prevalence of active HCV infection remains high in our area. There were no changes in the HCV genotype distribution. The number of patients with indication for HBV and HAV vaccination and receive these vaccines is low.     

Características clínicas y pronóstico de la neumonía adquirida en la comunidad causada por Staphylococcus aureus resistente a la meticilina

Introduction

The aim of this study is to describe the epidemiological and clinical features, treatment and prognosis of community-acquired pneumonia (CAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in two different geographic regions where community-acquired MRSA (CA-MRSA) infections have different frequencies.

Methods

Observational study of patients admitted to two hospitals (one in Argentina, the other in Spain) between March 2008 and June 2012.

Results

We documented 16 cases of CAP caused by MRSA. MRSA accounted for 15 of 547 (2.7%) cases of CAP in Hospital Rodolfo Rossi and 1 of 1258 (0,08%) cases at the Hospital Universitari de Bellvitge (P ≤ .001). Most patients were young and previously healthy. Multilobar infiltrates, cavitation and skin and soft tissue involvement were frequent. All patients had positive blood cultures. Five patients required admission to the intensive care unit. Early mortality (≤ 48 hours) was 19%, and overall mortality (≤ 30 days) was 25%.

Conclusion

CAP caused by MRSA causes high morbidity and mortality rates. It should be suspected in areas with a high prevalence of CA-MRSA infections, and especially in young and healthy patients who present with multilobar pneumonia with cavitation. Mortality is mainly related to septic shock and respiratory failure and occurs early in most cases.     

Indicadores de calidad asistencial para la atención de personas que viven con el virus de la inmunodeficiencia humana,adaptados a la edad pediátrica

Introduction

Since infection with human immunodeficiency virus (HIV) was first described, there have been many advances in its diagnosis, monitoring and treatment. However, few contributions are related to the area of health care quality.In this sense, the Spanish Study Group on AIDS (GESIDA) has developed a set of quality care indicators for adult patients living with HIV infection that includes a total of 66 indicators, 22 of which are considered to be relevant. Standards were calculated for each of them in order to reflect the level of the quality of care offered to these patients. Similar documents for pediatric patients are currently lacking.

Methods

Preparation of a set of quality care indicators applicable to pediatric patients based on the GESIDA document and the Spanish Guidelines for monitoring of pediatric patients infected with HIV. Each indicator was analysed with respect to the required standards in all patients under 18 years of age followed-up in our Unit, with the aim of evaluating the quality of care provided.

Results

A total of 61 indicators were collected (51 from the GESIDA document and 10 from currently available pediatric guidelines), 30 of which were considered to be relevant. An overall compliance of 81%-83% was obtained when assessing the relevant indicators.

Conclusion

The availability of health care quality standards is essential for the care of pediatric HIV-infected patients. The assessment of these indicators in our Unit yielded satisfactory results.     

Variabilidad circadiana de la oximetría de pulso en niños sanos menores de 7 años

Background

Peripheral oxygen saturation (SpO₂) measured by pulse oximetry is widely used in clinical practice, but its fluctuations over the course of the 24 h of a day have not been explored at length. Recently, we reported that children hospitalized due to non-cardiopulmonary causes had a circadian variation in SpO₂. This finding needed to be corroborated in healthy children, which is the objective of the present study.

Patients and methods

Healthy children residing in a state foster home were studied with pulse oximetry every 2 h for 24 h.

Results

Eighty two children were included in the study, ranging in age from one month to 6.5 years (average ± standard error of 3.06 ± 0.16 years), with a weight-for-length/height percentile of 65.5 ± 2.9. In 65 (79.3%) children, the SpO₂ levels followed a sinusoidal curve suggesting circadian rhythm. The total group of sinusoidal curves in this population had a mesor of 95.10 ± 0.08% SpO₂, period of 21.05 ± 0.54 h (in 53.8% of these children, the period was between 20 and 28 h). The maximum SpO₂ was reached at 3:14 PM ± 16 min, and the minimum at 5:16 AM ± 48 min. When the 24 h were divided into four periods, it was demonstrated that the highest SpO₂ levels were reached between 2 PM and 8 PM.

Conclusions

In this population of clinically healthy children, there was a circadian variation in pulse oximetry, with maximum values in the late afternoon and minimal values in the early morning.     

Considerar negativa una carga viral expresada como menor del límite inferior de cuantificación puede inducir a error en el diagnóstico y manejo terapéutico de la hepatitis C

Introduction

For years many clinical laboratories have routinely classified undetectable and unquantifiable levels of hepatitis C virus RNA (HCV-RNA) determined by RT-PCR as below limit of quantification (BLOQ). This practice might result in erroneous clinical decisions.

Aim

To assess the frequency and clinical relevance of assuming that samples that are BLOQ are negative.

Material and method

We performed a retrospective analysis of RNA determinations performed between 2009 and 2011 (Cobas/Taqman, lower LOQ: 15 IU/ml). We distinguished between samples classified as «undetectable» and those classified as «<1.50E + 01 IU/mL» (BLOQ).

Results

We analyzed 2.432 HCV-RNA measurements in 1.371 patients. RNA was BLOQ in 26 samples (1.07%) from 23 patients (1.68%). BLOQ results were highly prevalent among patients receiving Peg-Riba: 23 of 216 samples (10.6%) from 20 of 88 patients receiving treatment (22.7%). The clinical impact of BLOQ RNA samples was as follows: a) 2 patients initially considered to have negative results subsequently showed quantifiable RNA; b) 8 of 9 patients (88.9%) with BLOQ RNA at week 4 of treatment later showed sustained viral response; c) 3 patients with BLOQ RNA at weeks 12 and 48 of treatment relapsed; d) 4 patients with BLOQ RNA at week 24 and/or later had partial or breakthrough treatment responses, and e) in 5 patients the impact were null or could not be ascertained.

Conclusions

This study suggests that BLOQ HCV-RNA indicates viremia and that equating a BLOQ result with a negative result can lead to treatment errors. BLOQ results are highly prevalent in on-treatment patients. The results of HCV-RNA quantification should be classified clearly, distinguishing between undetectable levels and levels that are BLOQ.     

Utilidad de la detección del virus del papiloma humano en el cribado de neoplasia intraepitelial anal en pacientes con conductas de riesgo

Introduction

The incidence of intraepithelial anal neoplasia is increasing in certain risk behaviour groups, and human papillomavirus (HPV) infection is involved in its pathogenesis. The systematic use of anal cytology, and more recently HPV detection by hybrid capture and genotyping, have been introduced into screening programs in recent decades.

Material and methods

A retrospective cohort study was carried out on individuals with risk behaviours of developing intraepithelial anal neoplasia and who attended Sexually Transmitted Infections clinics in the Dermatology area of the Hospital Costa del Sol from January 2010 to December 2012. The intraepithelial anal neoplasia screening was performed using anal cytology and HPV genotyping.

Results

Half (50%) of the study population were HIV positive. A high frequency of anal dysplasia and presence of HPV in cytology (82.1%) and genotype (79%) was found. A statistically significant association (P < .005) was obtained between the presence of high-risk HPV genotypes and the presence of high-grade dysplasia in the second directed cytology. HPV genotyping enabled 17 cases (22%) of severe dysplasia to be identified that were under-diagnosed in the first cytology.

Conclusion

Cases of high-grade dysplasia can be under-diagnosed by a first anal cytology. Detection of HPV can supplement this procedure, leading to the identification of those patients most at risk of developing high-grade anal dysplasia.     

Intervención domiciliaria y variables predictoras para reingreso hospitalario en la enfermedad pulmonar obstructiva crónica agudizada

Background

Chronic obstructive pulmonary disease (COPD) exacerbation increases mortality and resources used associated with hospitalization. We studied whether early home monitoring reduces the rate of readmission and if there are any predictor variables.

Patients and methods

We performed a prospective, controlled, parallel-group study in patients who were hospitalized for COPD. Patients whose residence was within less than 15 km from the hospital were assigned to an interventional group (home visits by nurses about 48-72 hours after discharge), the remainder were assigned to a conventional care group. The rate of rehospitalization within the first month was compared between the two groups, as well as those variables that showed a predictive capability.

Results

Seventy one patients were included: 35 in the conventional care group and 36 in the interventional group. In the latter, the treatment was modified in 13 patients (36%). The hospital readmission rate was 17%, which was similar in both groups (P = .50). For every 5-year increase in age, the risk for readmission was 2.54 (95% CI, 1.06-5.07) and for each increase of 10 mmHg in PaCO₂, the risk of readmission was 8.34 (95% CI, 2.43-18.55).

Conclusions

Early home monitoring did not decrease the readmission rate during the first month. Older age and high PaCO₂ are factors that identify the group with a high risk for rehospitalization.     

Preparación con picosulfato sódico/citrato de magnesio en dosis fraccionadas para colonoscopias en turno de mañana realizadas entre las 2 y 6 horas posteriores a la ingesta de líquidos

Background

Split dosage of bowel preparations has been shown to substantially improve bowel cleansing.

Aim

To compare the split dose (SD) sodium picosulphate/magnesium oxide/anhydrous citric acid (Citrafleet^®) regimen for morning colonoscopies with standard cleansing the day before.

Methods

Consecutive outpatients were randomized to receive Citrafleet^® the day before colonoscopy or SD, in whom the second half was administered on an individual basis from 2 to 6 hours before the procedure. No bisacodyl was administered. All procedures were performed with non-anesthesiologist administered propofol sedation. The Boston scale was used to assess the quality of bowel preparation (adequate cleansing if score ≥ 6, with no score of 0/1 in any segment).

Results

A total of 193 patients were included. Overall bowel cleansing was significantly better in the SD group (7 vs. 5.2, p < 0.001), as well as in the cecum (2.4 vs. 1.4, p < 0.001), ascending colon (2.5 vs. 1.6, p < 0.001) and transverse colon (2.4 vs. 2, p = 0.004). A significant proportion of SD patients had adequate bowel cleansing (71% vs. 30%, p < 0.001). Patients in the SD group drank a greater amount of liquid (4.9 vs. 4 liters, p = 0.006) and more frequently perceived the cleansing process to be easy or very easy to complete (89 vs. 68%, p = 0.04), although they slept significantly fewer hours (6.5 vs. 7.9, p < 0.001). No bronchoaspiration pneumonia was reported.

Conclusions

SD Citrafleet^® 2 to 6 hours before colonoscopy increased the rate of procedures with adequate bowel cleansing by 40%, especially in the proximal colon, allowed more liquids to be drunk and increased the perception of ease in completing the preparation, with no sedation-related complications.     

Predicción en tiempo real de la malignidad de ganglios linfáticos mediastínicos mediante ecografía endobronquial

Objective

To evaluate the utility of different ultrasonographic (US) features in differentiating benign and malignant lymph node (LN) by endobronchial ultrasound (EBUS) and validate a score for real-time clinical application.

Methods

208 mediastinal LN acquired from 141 patients were analyzed. Six different US criteria were evaluated (short axis ≥ 10 mm, shape, margin, echogenicity, and central hilar structure [CHS], and presence of hyperechoic density) by two observers independently. A simplified score was generated where the presence of margin distinction, round shape and short axis ≥ 10 mm were scored as 1 and heterogeneous echogenicity and absence of CHS were scored as 1.5. The score was evaluated prospectively for real-time clinical application in 65 LN during EBUS procedure in 39 patients undertaken by two experienced operators. These criteria were correlated with the histopathological results and the sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated.

Results

Both heterogenicity and absence of CHS had the highest sensitivity and NPV (≥ 90%) for predicting LN malignancy with acceptable inter-observer agreement (92% and 87% respectively). On real-time application, the sensitivity and specificity of the score > 5 were 78% and 86% respectively; only the absence of CHS, round shape and size of LN were significantly associated with malignant LN.

Conclusions

Combination of different US criteria can be useful for prediction of mediastinal LN malignancy and valid for real-time clinical application.     

Colonización nasal por Staphylococcus aureus en estudiantes de medicina: importancia en la transmisión hospitalaria

Background

Staphylococcus aureus is the main pathogen causing nosocomial infections. Health professionals, including medical students, could be a source of transmission. The aims of the study were to determine the rate of nasal carriage of S. aureus susceptible and resistant to methicillin (MRSA) and evaluate the knowledge and adherence that students had about hand hygiene.

Methods

The study included medical students attached to the Hospital Universitario 12 de Octubre (Madrid, Spain). We collected samples from both nasal vestibules, and the antimicrobial susceptibility was determined on all isolates. Data collection was performed using a self-administered questionnaire that included risk factors for colonization, hygiene habits and knowledge of hand hygiene protocols.

Results

Of the 140 students included, 55 (39.3%) were colonized by S. aureus, and 3 (2,1%) by MRSA. The exposure to antibiotics in the last 3 months was lower in colonized students (12.3% vs. 25.9%, P = .03). Self-assessment showed that 56.4% of students almost never washed their hands before to attending to the first patient, and only 38.6% always washed after examining patients. More than a third (35.7%) ignored the hand hygiene protocol, and 38.6% had not received specific formation.

Conclusions

Medical students should be included in hospital infection control programs. Hand hygiene training should be given to students before they begin their practices in the hospital.     

Infecciones de piel y partes blandas en pacientes hospitalizados: factores epidemiológicos,microbiológicos,clínicos y pronósticos

Introduction

Skin and soft-tissue infections (SSTIs) are a frequent cause of consultation in emergence services, and complicated cases require hospitalization. However there are few data in our setting about the clinical characteristics of these infections.

Material and methods

A retrospective review of hospital admitted patients with a diagnosis of folliculitis, cellulitis, erysipelas, abscesses, hidradenitis, furuncle, impetigo, fasciitis and Fournier's gangrene. Cases were extracted from the data base of diagnostic codes of the Archive and Clinical Documentation Department of Son Llàtzer Hospital from January 2002 to November 2011.

Results

We studied 996 episodes in 841 hospitalized patients with any diagnosis of SSTIs. Cellulitis/erysipelas (66.7%) was the most frequently diagnosed condition, with 77% of all SSTIs being community acquired, and the majority of patients had comorbidities, mainly diabetes (33%) and heart failure (17.7%). The most frequent isolated microorganism was S. aureus (35.1%), in 19 (12.9%) cases with methicillin-resistance (MRSA), 84.2% of them were nosocomial or health care acquired. Monotherapy with aminopenicillin with clavulanic acid was the empiric treatment most frequently used (35.5%). New antibiotics for Gram-positive cocci (linezolid, daptomycin, and tigecycline) were used in patients with comorbidities that presented more complications (P < .001) and more risk of mortality (P = .001). During admission 10.9% of patients died, but only in 2.7% of them mortality was related to the SSTIs.

Conclusions

SSTIs attended most frequently in hospitalized patients are mainly cellulitis/erysipela, the majority community acquired. MRSA infections are mainly health care related. Use of new antibiotic for Gram-positive cocci was limited.