Atención de pacientes adultos con crisis epilépticas en servicios de urgencias (Registro ACESUR). Diferencias en función de la edad ≥ 75 años

ObjectivesTo determine whether there are differences in the profile and in the care of adult patients with epileptic seizures in emergency department according to age ≥ 75 years, and if this is independently associated with results in the emergency department and 30 days after discharge.Material and methodsACESUR is a multicentre, prospective, observational cohort multipurpose register that was carried out in 2017. The distribution of the variables corresponding to the clinical presentation and care according to age ≥ 75 years were compared. Subsequently, logistic regression models were performed with the objective of evaluating the effect of age ≥ 75 years on the outcome variables.ResultsA total of 541 (81.5%) cases younger than 75 years were analysed compared to 123 adult patients (18.5%) of ≥ 75 years or more. In the group of long-lived it was observed significantly greater probability of dependence, co-morbidity, polypharmacy, a previous visit to the hospital emergency department, arrived by ambulance, first seizures and a symptomatic aetiopathogenic classification. In the multivariate analysis, after adjusting for the above variables, it is observed that age > 75 years is associated independently with a higher incidence of specific supplementary tests (OR: 2.31; 95% CI: 1.21-4.44), but not pharmacological intervention (OR: 1.63; 95% CI: 0.96-2.80), or hospitalisation or extended stay in emergency departments (OR: 1.56; 95% CI: 0.94-2.59). On adjusting for all previous variables, age > 75 years is associated with lower incidence of adverse events at 30 days (OR: 0.43; 95% CI: 0.25-0.77).ConclusionsIn the ACESUR Registry, differences in clinical presentation and in the care of patients with seizures in emergency departments were identified when comparing those patients > 75 years with those < 75 years. Age ≥ 75 years is not independently associated with a higher incidence of intervention in emergency departments, or with more adverse outcomes at 30 days after discharge.     

Innovando en la toma de decisiones compartida con pacientes hospitalizados: descripción y evaluación de una herramienta de registro de nivel de intensidad terapéutica

Background and aimShared decision-making between patients and healthcare professionals is crucial to guarantee adequate coherence between patient values and preferences, caring aims and treatment intensity, which is key for the provision of patient-centred healthcare. The assessment of such interventions are essential for caring continuity purposes. To do this, reliable and easy-to-use assessment systems are required. This study describes the results of the implementation of a hospital treatment intensity assessment tool.Material and methodsThe pre-implementation and post-implementation results were compared between two cohorts of patients assessed for one month.ResultsSome record of care was registered in 6.1% of patients in the pre-implementation group (n = 673) compared to 31.6% of patients in the post-implementation group (n = 832) (P < .01), with differences between services. Hospital mortality in both cohorts is 1.9%; in the pre-implementation group, 93.75% of deceased patients had treatment intensity assessment.ConclusionsIn hospital settings, the availability of a specific tool seems to encourage very significantly shared decision-making processes between patients and healthcare professionals —multiplying by more than 5 times the treatment intensity assessment. Moreover, such tools help in the caring continuity processes between different teams and the personalisation of caring interventions to be monitored. More research is needed to continue improving shared decision-making for hospital patients     

Body size,duration of parental care,and the intrinsic rate of natural increase in eutherian and metatherian mammals

Summary The intrinsic rate of natural increase (r _m), conception to weaning time (t _cw), age of first reproduction (t_mat), and components of fecundity were compared between ecologically similar groups of 42 metatherian (=marsupial) and 42 eutherian mammals. Marsupial t _cw s average 50% longer than those of eutherians. Small marsupials (<400 g) mature later, and have lower and r _ms than eutherians; large marsupials (>10,000 g) do not mature later but also have lower r _ms. At body sizes of 1,000–3,500 g, marsupials and eutherians have similar t _mat s and t _cw s but marsupials have greater r _ms. Marsupials compensate for their longer t _cw s by a variety of methods including embryonic diapause, larger litter sizes, and short periods between weaning and maturity. Although the greatest similarities in marsupial and eutherian life histories are at body sizes of 1–5 kg, compensation for long t _cw may be seen at any marsupial body size. Other ecological factors not withstanding, marsupial reproduction is neither inherently inferior to that of eutherians nor obviously more advantageous in unpredictable environs.     

临床思维和决策能力的研究现状与思考

临床决策能力一直是医学教育者和管理者关注的热点,其研究体系已初步形成。本文简要回顾了临床决策思维的提出、概念及结合临床决策能力的培养体系、课程设置、理论教学法、实践教学法等方面归纳了国内外临床决策能力的研究现状,并由此提出对临床决策思维的思考。     

Evolutionary transitions among egg-laying,live-bearing and maternal inputs in sharks and rays

Sharks and rays are thought to have a large number of independent origins of live-bearing. We examined evolutionary transitions to live-bearing and maternal input to embryos in this subclass by optimizing reproductive characters onto a composite phylogeny. Egg-laying (40 per cent of all species) is the likely ancestral reproductive mode for this clade, and there is evidence that live-bearing has evolved independently 9–10 times and maternal input 4–5 times. Most transitions (12–15) have been toward live-bearing with provisioning limited to yolk. These have occurred from egg-laying ancestors or live-bearing taxa that provide maternal input to embryos. Only 2–3 transitions have occurred in the other direction, i.e. away from yolk-only bearing. Egg-laying has evolved from live-bearing ancestors in skates, Rajidae (25 per cent of all species) and possibly in the zebra shark, Stegostoma fasciata. Thus, although there has been an overall trend toward the evolution of live-bearing in elesmobranchs, the evolution of additional maternal input has been extremely labile.     

Potential use of Mucor circinelloides for the biological control of certain helminths affecting livestock reared in a care farm

A preliminary study to evaluate the possibilities of biological control procedures against parasites affecting livestock reared in a care farm has been conducted. Adults with mental disabilities were involved in spreading the spores of the filamentous fungus Mucor circinelloides directly onto the faeces, or as a food additive. In the first assay, the spores were sprayed directly onto the faeces of piglets and calves parasitised by roundworms (Ascaris suum) and liver flukes (Fasciola hepatica), respectively. In the second assay, the spores were mixed with on-farm mash feed. Participation of the adults in the experiments was fully satisfactory. In the manure sprayed Mucor spores, the viability of eggs of roundworms and flukes reduced by 53% and 74%, respectively. Significant reductions of viability of eggs of Ascaris (60%) and Fasciola (67%) in the faeces of piglets and calves given mash feed-added Mucor spores were achieved, which demonstrates their ability to survive in the digestive tract of the animals. It is concluded that biological control of parasites could be helpful to decrease the risk of infection in animals reared by intellectually disabled adults in a care farm, and it could motivate them to accomplish new tasks.     

Aspergilosis invasiva en el paciente crítico

Critically ill patients without severe immunosuppression make up a population in which invasive aspergillosis (IA) has been identified as an emergent pathology. Chronic treatment with corticosteroids, chronic obstructive pulmonary disease, and liver cirrhosis are repeatedly identified risk factors. However, due to the non-specificity of the symptoms and signs in the critical patient, and the relative low diagnostic capacity of the complementary tests, the diagnosis of the IA is a challenge for the specialist in critical care medicine. The application of diagnostic algorithms adapted to critical patients, in whom activation will depend on the isolation of Aspergillus in a respiratory specimen, is the most efficient diagnostic methodology in this population. Among the diagnostic approaches, the determination of galactomannan in bronchoalveolar fluid is the most useful diagnostic test. Once the suspicion is established, treatment should be started as soon as possible. Voriconazole, amphotericin B, and isavuconazole are the most effective treatments. Although voriconazole and amphotericin B are the drugs with the most scientific evidence, they are related with adverse effects and pharmacokinetic difficulties. Therefore, isavuconazole, which has shown high efficacy and safety in other populations, is a potential alternative of great interest for critically ill patients.     

突发公共卫生事件与综合性医院重症监护超负荷扩容

医院是社会应对突发公共卫生事件的主要机构。在超出正常负荷的情况下,合理有序地进行基础卫生设施扩容是保证医院成功应对突发事件的关键。医院必须能够通过增加重症监护单元（Intensive Care Unit, ICU）容量或通过改造其他区域增加实际ICU收治能力;有次序地将相关区域改造为临时重症监护单元;储备充足的病床和相关监护设施,在应对偶发事件时必须能得到政府协助以获取额外的呼吸机;制定ICU阶段性扩容人员工作计划,保证在应对偶发事件或危机时重症监护的仍可有效执行;抽调临床专业人员参与应急管理组,共同制定和执行扩容计划;为重症监护活动提供充足的基础设施支持。     

通过患者满意度调查评价护理质量

目的:通过患者满意度调查,进一步了解我院护理工作中的成效及存在问题,评价护理工作的质量,探索医院管理中护理科学管理方法。方法:①住院病人:采用问卷调查法;②出院病人:采用电话或上门随访方法;两种方法共对568例进行满意度调查,针对病人反馈的问题进行原因分析,提出改进措施并落实。结果:在疾病宣教及护理质量方面存在问题。结论:以医院管理年及创建优质护理服务为契机,以病人为中心,以质量为核心,逐步完善各项护理规章制度,加强护理安全管理,强化"三基三严"的训练,努力改善护理管理,提高护理服务质量。     

围手术期综合护理对脊柱损伤并四肢骨折疗效的影响

目的:探讨围手术期系统综合护理对脊柱损伤并四肢骨折疗效的影响。方法:收集50例脊柱损伤并四肢骨折患者,按手术编号随机分为观察组和对照组,每组各25例,两组患者均采用内固定手术及常规治疗,但观察组围手术期配合综合系统护理,对照组不配合,连续观察至出院并随访6个月,比较护理对比两组患者临床疗效、并发症情况及疾病恢复时间的影响。结果:经治疗,两组患者均较前好转,且观察组临床有效率92%明显高于对照组84%(P<0.05);观察组并发症发生率28%明显低于对照组44%(P<0.05);术后疾病恢复时间观察组明显短于对照组(P<0.05)。结论:围手术期综合系统护理有助于脊柱损伤并四肢骨折术后恢复,能显著提高疗效、减少并发症,缩短疾病恢复时间,临床值得应推广实施。