Análise da implementación da fisioterapia no paciente crítico no Servizo Galego de Saude

[Resumen] Introducción. La Fisioterapia tiene una gran efectividad en el ámbito de la Unidad de Cuidados Intensivos (UCI) y el tratamiento del paciente crítico. Éste último se caracteriza por tener diversas patologías y complicaciones clínicas asociadas en las que el fisioterapeuta juega un gran papel como parte del equipo interdisciplinario que tiene como objetivo último, la salida del paciente de la UCI con ninguna o una mínima limitación y en las mejores condiciones alcanzables de funcionalidad para que la reinserción del mismo a las actividades de la vida diaria sea igual o similar al que poseía antes del evento que lo condujo a la UCI. Se ha demostrado que la Fisioterapia aporta grandes beneficios y pocos riesgos a este tipo de pacientes. Tras pasar el periodo prioritario de salvar la vida del paciente, es importante un tratamiento fisioterápico bien pautado, con el fin de evitar complicaciones fruto de la propia afección y de la inmovilización que se sufre en estas unidades. El Servicio de Fisioterapia en estas unidades es clave para la reducción de la morbilidad, estancia hospitalaria, lo que influye directamente en los costes sanitarios, debido a la prevención de posibles complicaciones. Actualmente se dispone de algunos estudios que nos informan de la situación de la Fisioterapia en el ámbito hospitalario, pero pocos estudios aportan guías de práctica clínica o protocolos validados en las que apoyarnos. Objetivo. El objetivo de este estudio es describir la situación actual de la Fisioterapia en la Comunidad Autónoma Gallega en el ámbito asistencial de las Unidades de Cuidados Intensivos (UCI’s), tanto en los centros públicos como privados. Material y métodos. Partiendo del objetivo, es posible caracterizar esta investigación como un estudio descriptivo observacional de corte transversal, cuyo procedimiento de recogida de información es mediante cuestionario. Se utilizaron dos encuestas semiestructuradas las cuales fueron remitidas y cumplimentadas por el Jefe de Servicio de las UCIs y por los coordinadores del servicio de fisioterapia de los distintos centros hospitalarios gallegos durante los meses de diciembre y enero de 2020/21. Resultados. Para la realización de este estudio se han enviado un total de 28 encuestas (16 a centros hospitalarios del sector público y 12 al sector privado). La encuesta obtuvo un porcentaje de participación total del 57,14%. La tasa de respuesta de los centros de titularidad pública ha sido mayor, representado un 75% del estudio, frente a una participación de un 33,33% por parte de los centros privados. Todas las UCIs disponen de Servicio de Fisioterapia, con una ratio de 0 a 5 pacientes por fisioterapeuta en la sanidad pública mientras que en la privada se realiza según demanda. Este servicio es derivado mediante interconsulta con el Servicio de Rehabilitación (37%). Se le dedica un promedio de 16 a 30 min por paciente y sesión. A pesar de los turnos habituales de mañana y tarde, disponen de otros como urgencias o fines de semana, quedando excluido el de nocturnidad. El trabajo de los fisioterapeutas en UCI ha sido calificado como satisfactorio, aunque se considera que no cubre las necesidades asistenciales de la UCI. Conclusiones. La disponibilidad de los fisioterapeutas en la UCI es significativamente menos a las recomendaciones del Ministerio de Sanidad y Política Social y a las europeas vigentes. El grado de implementación en las UCIs gallegas es bajo. Se precisa de la elaboración de protocolos y guías de práctica clínica para el paciente crítico.[Abstract] Introduction. Physiotherapy is highly effective in the Intensive Care Unit (ICU) and in the treatment of the critically ill patient. The latter is characterized by various pathologies and associated clinical complications in which the physiotherapist plays a great role as part of the interdisciplinary team whose ultimate goal is the patient's exit from the ICU with no or minimal limitation and in the best achievable conditions of functionality so that the patient's reintegration to daily life activities is equal or similar to the one he/she had before the event that led him/her to the ICU. It has been demonstrated that Physiotherapy brings great benefits and few risks to this type of patient. After the priority period of saving the patient's life, it is important to have a well-planned physiotherapy treatment, in order to avoid complications resulting from the condition itself and the immobilization suffered in these units. The Physiotherapy Service in these units is key to the reduction of morbidity and hospital stay, which has a direct influence on health costs, due to the prevention of possible complications. There are currently some studies available that inform us of the situation of Physiotherapy in the hospital setting, but few studies provide clinical practice guidelines or validated protocols on which to rely. Objective. The aim of this study is to describe the current situation of Physiotherapy in the Galician Autonomous Community in the care setting of Intensive Care Units (ICU's), both in public and private centers. Material and methods. Based on the objective, it is possible to characterize this research as a cross-sectional observational descriptive study, whose procedure for collecting information is by means of a questionnaire. Two semi-structured surveys were used, which were sent to and completed by the Head of ICU Service and by the coordinators of the physiotherapy service of the different Galician hospitals during the months of December and January 2020/21. Results. A total of 28 surveys were sent out for this study (16 to public sector hospitals and 12 to the private sector). The survey obtained a total participation rate of 57.14%. The response rate of the publicly-owned centers was higher, representing 75% of the study, compared to a participation rate of 33.33% for the private centers. All the ICUs have a Physiotherapy Service, with a ratio of 0 to 5 patients per physiotherapist in the public health centers, while in the private centers this service is provided according to demand. This service is referred by interconsultation with the Rehabilitation Service (37%). An average of 16 to 30 minutes per patient per session is dedicated to this service. In spite of the usual morning and afternoon shifts, they have other shifts such as emergencies or weekends, excluding night shifts. The work of the physiotherapists in the ICU has been rated as satisfactory, although it is considered that it does not cover the care needs of the ICU. Conclusions. The availability of physiotherapists in the ICU is significantly less than the recommendations of the Ministry of Health and Social Policy and the European recommendations in force. The degree of implementation in Galician ICUs is low. The development of protocols and clinical practice guidelines for the critically ill patient is needed.[Resumo] Introdución. A Fisioterapia ten unha gran efectividade na área da Unidade de Coidados Intensivos (UCI) e o tratamento do paciente crítico. Este último caracterizase por ter varias patoloxías e complicacións clínicas asociadas nas que o fisioterapeuta xoga un gran papel como parte do equipo interdisciplinario cuxo obxectivo final, a saída do paciente da UCI con ningunha ou unha mínima limitación e nas mellores condicións alcanzables de funcionalidade para que a reinserción do mesmo as actividades da vida diaria sexa igual o similar a que tivo antes do suceso que o levou a UCI. Demostrouse que la Fisioterapia aporta grandes beneficios e poucos riscos para este tipo de pacientes. Despois de pasar o período prioritario de salvar a vida do paciente, é importante un tratamento fisioterápico ben planificado para evitar complicacións derivadas da propia enfermidade e da inmobilización sufrida nestas unidades. O Servizo de Fisioterapia nestas unidades é clave para reducir a morbilidade e a estancia hospitalaria, o que inflúe directamente nos custos sanitarios, debido a prevención de posibles complicacións. Na actualidade, disponse de algúns estudos que nos informan da situación da Fisioterapia no ámbito hospitalario, pero poucos estudos aportan guías de práctica clínica ou protocolos validados nos que apoiarnos. Objectivo. O obxectivo deste estudo é describir a situación actual da Fisioterapia na Comunidade Autónoma Galega no ámbito asistencial das Unidades de Coidados Intensivos (UCI’s), tanto nos centros públicos como privados. Material e métodos. Partindo do obxectivo, e posible caracterizar esta investigación como un estudo descritivo observacional de corte transversal, cuxo procedemento de recollida de información é a través de cuestionario. Utilizaronse dúas enquisas semiestructuradas as cales foron remitidas e cubertas polo Xefe de Servizo das UCIs e por os coordinadores do servizo de fisioterapia dos distintos centros hospitalarios galegos ó largo dos meses de decembro de 2020 e Xaneiro de 2021. Resultados. Para a realización deste estudo enviáronse un total de 28 enquisas (16 a centros hospitalarios do sector público e 12 ó sector privado). A enquisa obtivo unha porcentaxe de participación total do 57,14%. A tasa de resposta dos centros de titularidade pública foi maior, representado un 75% do estudo, frente a unha participación de un 33,33% pola parte dos centros privados. Tódalas UCIs dispoñen de Servicio de Fisioterapia, cun ratio de 0 a 5 doentes por fisioterapeuta na sanidad pública mentres que na privada realizase según demanda. Este servizo derívase mediante interconsulta co Servizo de Rehabilitación (37%). Dedícaselle una media de 16 a 30 min. por doente e sesión. A pesar das quendas habituais de maña e tarde, dispoñen de outras como urxencias ou fins de semana, excluíndose a de nocturnidad. O traballo dos fisioterapeutas na UCI foi calificado como satisfactorio, aínda que non cubre as necesidades asistenciais da UCI. Conclusións. A dispoñibilidade dos fisioterapeutas na UCI é significativamente menor as recomendacións do Ministerio de Sanidade e Política Social e as europeas vixentes. O grado de implementación nas UCIs galegas é baixo. Precisase da elaboración de protocolos e guías de práctica clínica para o doente crítico.Traballo fin de grao (UDC.FCS). Fisioterapia. Curso 2020/202

Role of age and comorbidities in mortality of patients with infective endocarditis

[Purpose]: The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality. [Methods]: Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk. [Results]: A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32–3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39–1.88),and non-performed surgery (HR:1.64;95% CI:11.16–1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality. [Conclusion]: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p &lt; 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics

Prediction of long-term outcomes of HIV-infected patients developing non-AIDS events using a multistate approach

Outcomes of people living with HIV (PLWH) developing non-AIDS events (NAEs) remain poorly defined. We aimed to classify NAEs according to severity, and to describe clinical outcomes and prognostic factors after NAE occurrence using data from CoRIS, a large Spanish HIV cohort from 2004 to 2013. Prospective multicenter cohort study. Using a multistate approach we estimated 3 transition probabilities: from alive and NAE-free to alive and NAE-experienced ("NAE development"); from alive and NAE-experienced to death ("Death after NAE"); and from alive and NAE-free to death ("Death without NAE"). We analyzed the effect of different covariates, including demographic, immunologic and virologic data, on death or NAE development, based on estimates of hazard ratios (HR). We focused on the transition "Death after NAE". 8,789 PLWH were followed-up until death, cohort censoring or loss to follow-up. 792 first incident NAEs occurred in 9.01% PLWH (incidence rate 28.76; 95% confidence interval [CI], 26.80-30.84, per 1000 patient-years). 112 (14.14%) NAE-experienced PLWH and 240 (2.73%) NAE-free PLWH died. Adjusted HR for the transition "Death after NAE" was 12.1 (95%CI, 4.90-29.89). There was a graded increase in the adjusted HRs for mortality according to NAE severity category: HR (95%CI), 4.02 (2.45-6.57) for intermediate-severity; and 9.85 (5.45-17.81) for serious NAEs compared to low-severity NAEs. Male sex (HR 2.04; 95% CI, 1.11-3.84), ag

Discovering HIV related information by means of association rules and machine learning

Acquired immunodeficiency syndrome (AIDS) is still one of the main health problems worldwide. It is therefore essential to keep making progress in improving the prognosis and quality of life of affected patients. One way to advance along this pathway is to uncover connections between other disorders associated with HIV/AIDS-so that they can be anticipated and possibly mitigated. We propose to achieve this by using Association Rules (ARs). They allow us to represent the dependencies between a number of diseases and other specific diseases. However, classical techniques systematically generate every AR meeting some minimal conditions on data frequency, hence generating a vast amount of uninteresting ARs, which need to be filtered out. The lack of manually annotated ARs has favored unsupervised filtering, even though they produce limited results. In this paper, we propose a semi-supervised system, able to identify relevant ARs among HIV-related diseases with a minimal amount of annotated training data. Our system has been able to extract a good number of relationships between HIV-related diseases that have been previously detected in the literature but are scattered and are often little known. Furthermore, a number of plausible new relationships have shown up which deserve further investigation by qualified medical experts

Impact of late presentation of HIV infection on short-, mid- and long-term mortality and causes of death in a multicenter national cohort : 2004-2013

To analyze the impact of late presentation (LP) on overall mortality and causes of death and describe LP trends and risk factors (2004-2013). Cox models and logistic regression were used to analyze data from a nation-wide cohort in Spain. LP is defined as being diagnosed when CD4 < 350 cells/ml or AIDS. Of 7165 new HIV diagnoses, 46.9% (CI:45.7-48.0) were LP, 240 patients died.First-year mortality was the highest (aHR = 10.3[CI:5.5-19.3]); between 1 and 4 years post-diagnosis, aHR = 1.9(1.2-3.0); an

Effectiveness of the combination elvitegravir/cobicistat/tenofovir/emtricitabine (EVG/COB/TFV/FTC) plus darunavir among treatment-experienced patients in clinical practice : A multicentre cohort study

Background: The aim of this study was to investigate the effectiveness and tolerability of the combination elvitegravir/cobicistat/tenofovir/emtricitabine plus darunavir (EVG/COB/TFV/FTC + DRV) in treatment-experienced patients from the cohort of the Spanish HIV/AIDS Research Network (CoRIS). Methods: Treatment-experienced patients starting treatment with EVG/COB/TFV/FTC + DRV during the years 2014-2018 and with more than 24 weeks of follow-up were included. TFV could be administered either as tenofovir disoproxil fumarate or tenofovir alafenamide. We evaluated virological response, defined as viral load (VL) < 50 copies/ml and < 200 copies/ml at 24 and 48 weeks after starting this regimen, stratified by baseline VL (< 50 or ≥ 50 copies/ml at the start of the regimen). Results: We included 39 patients (12.8% women). At baseline, 10 (25.6%) patients had VL < 50 copies/ml and 29 (74.4%) had ≥ 50 copies/ml. Among patients with baseline VL < 50 copies/ml, 85.7% and 80.0% had VL < 50 copies/ml at 24 and 48 weeks, respectively, and 100% had VL < 200 copies/ml at 24 and 48 weeks. Among patients with baseline VL ≥ 50 copies/ml, 42.3% and 40.9% had VL < 50 copies/ml and 69.2% and 68.2% had VL < 200 copies/ml at 24 and 48 weeks. During the first 48 weeks, no patients changed their treatment due to toxicity, and 4 patients (all with baseline VL ≥ 50 copies/ml) changed due to virological failure. Conclusions: EVG/COB/TFV/FTC + DRV was well tolerated and effective in treatment-experienced patients with undetectable viral load as a simplification strategy, allowing once-daily, two-pill regimen with three antiretroviral drug classes. Effectiveness was low in patients with detectable viral loads

COVID-19 in hospitalized HIV-positive and HIV-negative patients : A matched study

CatedresObjectives: We compared the characteristics and clinical outcomes of hospitalized individuals with COVID-19 with [people with HIV (PWH)] and without (non-PWH) HIV co-infection in Spain during the first wave of the pandemic. Methods: This was a retrospective matched cohort study. People with HIV were identified by reviewing clinical records and laboratory registries of 10 922 patients in active-follow-up within the Spanish HIV Research Network (CoRIS) up to 30 June 2020. Each hospitalized PWH was matched with five non-PWH of the same age and sex randomly selected from COVID-19@Spain, a multicentre cohort of 4035 patients hospitalized with confirmed COVID-19. The main outcome was all-cause in-hospital mortality. Results: Forty-five PWH with PCR-confirmed COVID-19 were identified in CoRIS, 21 of whom were hospitalized. A total of 105 age/sex-matched controls were selected from the COVID-19@Spain cohort. The median age in both groups was 53 (Q1-Q3, 46-56) years, and 90.5% were men. In PWH, 19.1% were injecting drug users, 95.2% were on antiretroviral therapy, 94.4% had HIV-RNA < 50 copies/mL, and the median (Q1-Q3) CD4 count was 595 (349-798) cells/μL. No statistically significant differences were found between PWH and non-PWH in number of comorbidities, presenting signs and symptoms, laboratory parameters, radiology findings and severity scores on admission. Corticosteroids were administered to 33.3% and 27.4% of PWH and non-PWH, respectively (P = 0.580). Deaths during admission were documented in two (9.5%) PWH and 12 (11.4%) non-PWH (P = 0.800). Conclusions: Our findings suggest that well-controlled HIV infection does not modify the clinical presentation or worsen clinical outcomes of COVID-19 hospitalization

Assembling the Dead, Gathering the Living: Radiocarbon Dating and Bayesian Modelling for Copper Age Valencina de la Concepción (Seville, Spain)

The great site of Valencina de la Concepción, near Seville in the lower Guadalquivir valley of southwest Spain, is presented in the context of debate about the nature of Copper Age society in southern Iberia as a whole. Many aspects of the layout, use, character and development of Valencina remain unclear, just as there are major unresolved questions about the kind of society represented there and in southern Iberia, from the late fourth to the late third millennium cal BC. This paper discusses 178 radiocarbon dates, from 17 excavated sectors within the c. 450 ha site, making it the best dated in later Iberian prehistory as a whole. Dates are modelled in a Bayesian statistical framework. The resulting formal date estimates provide the basis for both a new epistemological approach to the site and a much more detailed narrative of its development than previously available. Beginning in the 32nd century cal BC, a long-lasting tradition of simple, mainly collective and often successive burial was established at the site. Mud-vaulted tholoi appear to belong to the 29th or 28th centuries cal BC; large stone-vaulted tholoi such as La Pastora appear to date later in the sequence. There is plenty of evidence for a wide range of other activity, but no clear sign of permanent, large-scale residence or public buildings or spaces. Results in general support a model of increasingly competitive but ultimately unstable social relations, through various phases of emergence, social competition, display and hierarchisation, and eventual decline, over a period of c. 900 years