Third-level Hospitals Research Articles

Prospective study of renal function in HIV-infected pediatric patients receiving tenofovir-containing HAART regimens

to describe the impact of tenofovir disoproxil fumarate (TDF) use on renal function in HIV-infected pediatric patients. it is a prospective, multicenter study. The setting consisted of five third-level pediatric hospitals in Spain. The study was conducted on patients aged 18 years and younger who had received TDF for at least 6 months. The intervention was based on the study of renal function parameters by urine and serum analyses. The main outcome measures were renal function results following at least 6 months of TDF therapy. forty patients were included (32 were white and 26 were diagnosed with AIDS). Median (range) duration of TDF treatment was 77 months (16-143). There were no significant changes in the estimated creatinine clearance. Urine osmolality was abnormal in eight of 37 patients, a decrease in tubular phosphate absorption was documented in 28 of 38 patients, and 33 of 37 patients had proteinuria. A statistically significant decrease in serum phosphate and potassium concentrations was observed during treatment (P = 0.005 and P = 0.003, respectively), as well as a significant relationship between final phosphate concentration and tubular phosphate absorption (P = 0.010). A negative correlation was found between phosphate concentration and time on TDF. TDF use showed a significant association with renal tubular dysfunction in HIV-infected pediatric patients. Periodic assessment of tubular function may be advisable in the follow-up of this population.

Neurocysticercosis May No Longer Be a Public Health Problem in Mexico

Neurocysticercosis May No Longer Be a Public Health Problem in Mexico

¿Está de acuerdo nuestra conducta ante el nódulo tiroideo y cáncer diferenciado de tiroides con la guía norteamericana y el consenso europeo?

Introduction The aim of this study was to assess the approaches of specialists in Spain to patients with thyroid nodules and differentiated thyroid carcinoma and to compare them with the American guideline and European consensus. Material and methods We performed a cross-sectional study based on a questionnaire addressed to clinical endocrinologists specialized in thyroid cancer and specialists in nuclear medicine throughout Spain. Results A total of 177 questionnaires were completed, representing an overall response rate of 85%; 74% of responses were from endocrinologists and 24% from physicians active in nuclear medicine; 82% of respondents worked in third-level hospitals, 10% in second level hospitals and the remainder in private practice. Most used ultrasonography and cytology to assess thyroid nodules and collaborated with a group of surgeons expert in thyroid surgery. The majority preferred total or subtotal thyroidectomy in tumors with a diameter of 1 cm or more, and systematic lymph node dissection. Only 43 (24%) preferred prophylactic central lymph node dissection. Eighty-one respondents (45%) would still use whole body scan with 131I or 123I before 131I ablation. Follow-up was based on cervical echography and thyroglobulin determination; however, 101 (57%) respondents continued to use diagnostic whole body scan in the follow-up. Conclusion The approaches of the respondents were mainly in accordance with the guideline and consensus, although some variations were found, especially in the use of whole body scan with 131I before ablation and in follow-up.

Surveillance study of apparent life-threatening events (ALTE) in the Netherlands

SIDS and ALTE are different entities that somehow show some similarities. Both constitute heterogeneous conditions. The Netherlands is a low-incidence country for SIDS. To study whether the same would hold for ALTE, we studied the incidence, etiology, and current treatment of ALTE in The Netherlands. Using the Dutch Pediatric Surveillance Unit, pediatricians working in second- and third-level hospitals in the Netherlands were asked to report any case of ALTE presented in their hospital from January 2002 to January 2003. A questionnaire was subsequently sent to collect personal data, data on pregnancy and birth, condition preceding the incident, the incident itself, condition after the incident, investigations performed, monitoring or treatment initiated during admission, any diagnosis made at discharge, and treatment or parental support offered after discharge. A total of 115 cases of ALTE were reported, of which 110 questionnaires were filled in and returned (response rate 97%). Based on the national birth rate of 200,000, the incidence of ALTE amounted 0.58/1,000 live born infants. No deaths occurred. Clinical diagnoses could be assessed in 58.2%. Most frequent diagnoses were (percentages of the total of 110 cases) gastro-esophageal reflux and respiratory tract infection (37.3% and 8.2%, respectively); main symptoms were change of color and muscle tone, choking, and gagging. The differences in diagnoses are heterogeneous. In 34%, parents shook their infants, which is alarmingly high. Pre- and postmature infants were overrepresented in this survey (29.5% and 8.2%, respectively). Ten percent had recurrent ALTE. In total, 15.5% of the infants were discharged with a home monitor. In conclusion, ALTE has a low incidence in second- and third-level hospitals in the Netherlands. Parents should be systematically informed about the possible devastating effects of shaking an infant. Careful history taking and targeted additional investigations are of utmost importance.

The relationship between job stressors,mental health and intention to quit of pediatric nurses

Objective To explore the relationship between job stressors,montal health and intention to quit of pediatric nurses by comparing with nurses in internal medicine department. Methods Job stressors, mental health,intention to quit of pediatric nurses and their relationship were investigated among nurses in above mentioned wards from three third-level and first-class hospitals by using questionnaires. Results The scores of some factors of job stressors and nine factors of SCL- 90 of pediatric nurses were much higher than those of internal medicine nurses. There was a significantly positive correlation between some factors of job stressors, mental health and intention to quit of pediatric nurses. Conclusions Working pressure is a factor of low mental health level and intention to quit of pediatric nurses. Effective management strategies should be imple-mented to protect the mental health of pediatric nurses and decrease the loss of nurses. Key words: Nurse; Stressor; Intention to quit; Psychophylaxis

Prescripción de Medicamentos en Pacientes Atendidos en Instituciones de Mediano y Alto Nivel de Complejidad

Determining prescription patterns for outpatient medication authorised for patients affiliated to an EPS and assisted by medium- and high-level complexity IPS. This was a cross-sectional study where medication prescription was evaluated in 331 second- and third-level complexity hospitals from 27 Colombian departments during 2006. 38 863 prescriptions for 3 663 patients' medication were analysed. 61,4 % came from third-level complexity hospitals, mainly for patients affiliated to contribution-based regimes. Average prescribed medication per person was 2,2 (2,1-2,2 95 % CI), the percentage of antibiotics formulated by prescription was 29,2 % (28,7-29,6 95 % CI), essential prescribed medicines accounted for 64,2 % (63,7-64,6 95 % CI) and injectable medicines was 22,1 % (21,7-25,5 %). More than half the medications (62,1 %; 61,5-62,7 95 % CI) were in ATC groups such as anti-infectious agents, immunomodulating agents and medications for the alimentary and metabolic tract. DU90% consisted of 64 medications, medication consumption being 8,39 daily de-fined doses (DDD)/1 000 patients, costing 5 216 Colombian pesos per DDD. This analysis led to identifying medications whose formulation frequency did not correlate with an epidemiologic profile as immunomudulator and growth-hormone (somatotropin) agents. There were differences in the frequency and quantity of DDD medications authorised by type of affiliation which could thus be providing evidence of obstacles to the population having access to drugs/medicaments.

Interval from diagnosis to treatment onset for six major cancers in Catalonia, Spain

Background: Targets set by health care organizations on time intervals between cancer diagnosis and treatment often go unmet. The objective of the study was to analyse the interval from diagnosis to treatment onset, and related factors, in the six most incident cancers in Catalonia (Spain), a developed European region with universal free access to health care. Methods: Twenty-two hospitals contributed 1023 incident cancer patients (198 lung, 253 colorectal, 95 prostate, 109 urinary bladder, 266 breast, 102 endometrial). Information was gathered from hospital medical records. The dependent variable was the length of the diagnosis to treatment interval (DTI). Independent variables were age, sex, disease stage, hospital level, mode of admission to hospital, and type of physician seen before admission. Multivariate-adjusted odds ratios were calculated by unconditional logistic regression for each cancer site. Results: The median DTI (in days) was 39 for lung cancer, 25 for colorectal, 108 for prostate, 69 for bladder, 35 for breast and 40 for endometrial cancer. In prostate and bladder cancers, over 78% of patients showed a DTI >30 days, while in colorectal the figure was 42%. Disseminated stage (distant metastases) was associated with a lower DTI in all sites. Patients admitted to third-level hospitals and with an elective admission were more likely to have a DTI >30 days. Conclusions: In Catalonia, a substantial proportion of cancer patients experience treatment delays that may impact negatively on psychological well-being, quality of life, and probably survival as well.

Laparoscopic Learning Evaluation over the Internet

Learning and refining laparoscopic surgical technique requires a continuous training process. For this learning process to have value, it must include objective evaluations and the interaction of expert surgeons. These surgeons, however, are normally located at third-level hospitals, so it is difficult for them to be available for this important process. In order to bring together learning and evaluation, we developed an Internet-based evaluation system for laparoscopic surgical technique. The system applies the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) evaluation methodology, and is remotely supervised by surgeons who specialize in laparoscopy.

Quality indicators and specifications for key processes in clinical laboratories: a preliminary experience

The aim of this study was to identify process indicators for the three phases of laboratory activity and their corresponding quality specifications in our setting (primary care centers, and second- and third-level hospitals that provide public healthcare services in Catalonia). Every 2 months, working group members met to present data obtained for quality indicators for the current processes in their laboratories. The results collected were for indicators recorded monthly from 2005 and for indicators recorded less frequently from 2004. The medians of the results obtained in all laboratories were calculated and the values obtained were established as the current specifications for the corresponding indicators. The laboratories participating in this working group use 12 indicators for the key processes (three for preanalytical steps, four for analytical steps and five for postanalytical steps). The preanalytical indicators are erroneous request, erroneous sample, and samples not taken, with specifications of 4.1%, 5.0% and 1.7%, respectively. A new indicator for the analytical step is the percentage of external controls exceeding the specification (0.8%); specifications for the other three well-recognized indicators (imprecision, bias and total error) are not the subject of this study. For the postanalytical phase, the indicators (and specifications) include duplicate hard copies of reports sent to centers or clinical units (1.6%), failure in critical value reporting (0.5%), reports exceeding delivery time (0.7%), reports from referred tests that exceed delivery time (8.9%), and incidents related to the data processing network between centers (25 events per year). The process indicators reflect the state-of-the-art of the laboratories comprising our working group. Current performance for the analytical phase is satisfactory because it is entirely in the hands of the laboratory, while the main problems in extra-analytical phases reside in activities performed outside the laboratory (sample collection and transport, as well as non-electronic report delivery).

Resistencia Antimicrobiana en Unidades de Cuidado Intensivo de Bogotá, Colombia, 2001-2003

Determining the frequency of antimicrobial resistance amongst bacterial isolates obtained from patients in Intensive Care Units (ICU). Study data relating to 2001 to 2003 regarding microbiological isolates was obtained from a laboratory network for the ICUs of 14 third-level hospitals in Bogotá belonging to the Bogotá Bacterial Resistance Control Group (BBRCG). 27,301 isolates were obtained and their susceptibility profiles were analysed using WHONET 5.3. Staphylococcus aureus, Escherichia coli, coagulase negative Staphylococci (CNS), Pseudomonas aeruginosa y Klebsiella pneumoniae were the most commonly found microorganisms. Oxacillin-resistance rate ranged from 61% at 63% during 2001 to 2003 amongst S. aureus isolates and 78% to 83% amongst coagulase negative Staphylococci (CNS). E. coli resistance to third generation cephalosporines was found to be about 10% and over 20% to ciprofloxacin. K. pneumoniae isolates' resistance to third-generation cephalosporines was found to be more than 30% in 2001. P. aeruginosa resistance to all but a few antibiotics was found to be over 30% and multirresistance frequency was found to be 16% to 24%. The antimicrobial resistance rates found in the ICU of hospitals in Bogotá were higher than those reported in surveillance studies in the USA, Europe or other Latin-American cities.

Spontaneous coronary artery dissection causing acute coronary syndrome: an early diagnosis implies a good prognosis.

Spontaneous coronary artery dissection is an unusual cause of acute coronary syndrome. We describe a series of cases that with an early diagnosis and aggressive treatment, which includes percutaneous angioplasty with stent implantation and cardiac surgery, had a good outcome. The objective was to study the demographic characteristics, clinical settings, treatments, and inhospital course of patients with spontaneous coronary artery dissection. We studied a retrospective case series in 3 coronary care units in third-level university hospitals. The spontaneous coronary artery dissection diagnosis was made by coronary angiography. Seven cases of spontaneous coronary artery dissections were recorded. They were 5 women and 2 men. The age range was 28 to 64 years. Two of them took oral contraceptives and one case occurred in the postpartum period. An acute anterior wall myocardial infarction was the most frequent clinical presentation, occurring in 4 of the 7 cases. In fact, the left anterior descending artery was involved in 6 cases. An urgent coronary angiogram was performed in all cases. Definitive treatment included percutaneous angioplasty and stent implantation in 3 cases, coronary artery bypass surgery in 2 case, and cardiac transplantation in another case. One patient was treated medically. None of the patients died in the hospital. Spontaneous coronary artery dissection remains an unusual cause of acute coronary syndrome. It should be included in the differential diagnosis of acute myocardial infarction, especially when it affects young, healthy females. An early clinical suspicion and diagnosis with urgent coronary angiography and aggressive treatment that includes percutaneous angioplasty with stent implantation and cardiac surgery could improve the prognosis of these patients.

Role of fibre and fruit in the Mediterranean diet to protect against myocardial infarction: a case–control study in Spain

To assess the association between a first acute myocardial infarction and the consumption of fibre and fruit. Hospital-based case-control study with incident cases. A validated semi-quantitative food frequency questionnaire (136 items) was used to assess food intake. Three third-level university hospitals in Pamplona (Spain). Cases were subjects aged under 80, newly diagnosed with acute myocardial infarction. Each case patient (n=171) was matched to a control subject of the same gender and age (5 y bands) admitted to the same hospital. An inverse association was apparent for the three upper quintiles of fibre intake. After adjustment for non-dietary and dietary confounders, an inverse linear trend was clearly significant, showing the highest relative reduction of risk (86%) for the fifth quintile (OR=0.14, 95% confidence interval: 0.03-0.67). An inverse association was also apparent for fruit intake, but not for vegetables or legumes. Our data suggest that a substantial part of the postulated benefits of the Mediterranean diet on coronary risk might be attributed to a high intake of fibre and fruit.

Prevalencia de infección por Chlamydia trachomatis determinada mediante métodos de biología molecular

To determine the prevalence of Chlamydia trachomatis infection in our area by molecular methods. We describe the combined results of three studies carried out in the city of Barcelona including a total of 408 women considered to be at high risk for acquiring a sexually transmitted disease (STD). The first study was performed in 94 women attended at a public STD clinic located downtown, the second in 112 women attended at the Hospital Clinic and the third in 202 women attended at Hospital Vall d'Hebron (both third-level hospitals). In the first and third study endocervical exudate was tested with a PCR technique, and in the second study LCR was performed in 20-ml urine samples. Chlamydia trachomatis was detected in 1 woman in the first study, in no women in the second and in 3 women in the third. The prevalence of Chlamydia trachomatis infection detected in the three studies using molecular biology techniques was 1.06%, 0% and 1.48% respectively, giving an overall prevalence of 0.98%. The prevalence of Chlamydia trachomatis infection in our geographic area is surprisingly low.

Manejo del traumatismo craneoencefálico leve en España: encuesta multicéntrica nacional

Despite of the high incidence of minor head injury, there is still controversy and disparity of criteria regarding its management. The lack of consensual protocols and clinical guidelines can lead to deficiencies in the attention to these patients and to inadequate use of resources. The objective of this study has been to describe the present situation of the management of this entity in the neurosurgical departments of the Spanish public hospitals, and to compare it with other European countries. A 57-item questionnaire regarding different aspects of minor head injury was designed and distributed to the 66 neurosurgical departments of the Spanish National Health System between December 1999 and February 2000. A 83.3% of responses were obtained. More than 92,000 patients per year are assisted at the Spanish third-level hospitals (general hospitals) after suffering a minor head injury. In-hospital on duty neurosurgeons are not available in 49.1% of the Spanish neurosurgical departments. Only in 7.3% of the centres the neurosurgeon is the first physician that assists these patients. However, in 52.7% of the hospitals neurosurgical evaluation is required if the patient refers transient loss of consciousness. A GCS score of 13 is still included in the group of minor head injuries in 29.1% of the centres. Although 89.1% of the surveyed neurosurgical departments considered as satisfactory the attention they provide to these patients, 85.5% think that it would be convenient to elaborate clinical guidelines. Cranial x-ray is considered a useful diagnostic tool by only 38.2% of the centres, however, 89.1% of them still use it as a routine. CT-scan is systematically indicated in all patients after suffering a mild head trauma only in 5.5% of the centres, although it is completely available in 74.5% of them. The study of economical costs shows that choosing cranial CT as screening tool in these patients would mean a 40.6% reduction in costs compared to a management based on x-ray plus in-hospital observation. This study shows the inter-hospital variability of minor head injury management in Spain. Clinical guidelines are considered as positive and necessary. Although the Spanish situation is similar to that in other European countries, following the tendency toward a broader cranial CT utilisation, would improve diagnosis profitability and economical efficiency. The results of this study may contribute to the creation of consensual protocols and clinical guidelines in our country that help in daily practice decision-making optimising assistance quality.

Kangaroo mother care in low-income countries. International Network in Kangaroo Mother Care.

Kangaroo mother care represents an appropriate affordable high-quality approach to the care of low-birth-weight infants in developing countries. This approach entails early prolonged and continuous skin-to-skin contact between the mother and infant both in hospital and after discharge with exclusive breast feeding. An international workshop convened in Trieste Italy in 1996 reached consensus on the use of kangaroo mother care in first-level facilities and third-level hospitals in countries with very limited resources. In practice all low-birth-weight infants who are breathing well and free from severe disease or malformation are eligible for this technology if the mother is available. In-service training on kangaroo mother care should be organized in every hospital providing care for low-birth-weight infants. This article describes in detail the protocol for implementation of this technology in low-income countries.