La utilización de prácticas inefectivas en Atención Primaria: Opinión de los profesionales.

Objetivo: Estimar la frecuencia en el uso de prácticas inefectivas en el ámbito de la Atención Primaria, en base a la opinión de profesionales clínicos que trabajen en ese ámbito, así como valorar la importancia que los médicos de atención primaria conceden a la utilización de esas prácticas inefectivas en su ámbito profesional, las consecuencias que pueden estar ocasionando y los factores que pueden estar contribuyendo a su mantenimiento. Material y métodos: A partir de la lista de intervenciones consideradas infectivas por algunas organizaciones internacionales (Choosing – Wisely) en el ámbito de la atención primaria se diseñó una encuesta de opinión sobre la utilización de dichas intervenciones que fue administrada por vía “on line” a una muestra de conveniencia compuesta por 575 profesionales de la atención primaria seleccionados a partir de las direcciones de contacto que constaban en los artículos publicados en los dos últimos años de las revistas Atención Primaria y Semergen. Se analizaron las frecuencias de respuesta y las posibles diferencias en relación con las características sociodemográficas de los encuestados mediante los test de Chi cuadrado (variables cualitativas) y Kruskal-Wallis (variables cuantitativas). Resultados: La tasa de respuesta fue del 37% (n=212), en su mayoría eran varones (59%), de entre 50 y 50 años (42,0%), con más de 20 años de experiencia profesional (50,5%) y que acostumbran a leer más de 20 artículos científicos al año (69,7%). Para el 70,6 % [IC95%: 64,5-73,7] de los encuestados el problema de la sobremedicación, el sobrediagnóstico o sobretratamiento es frecuente o muy frecuente en el ámbito de la AP y el 31% [IC95%: 24,7-37,3] manifestaba que más del 25% de las prácticas de AP deberían dejar de hacerse por inefectivas. En conjunto valoraron la importancia de este problema en su ámbito de trabajo con una media de 7,3 (DE=1,8) sobre 10, siendo esta valoración significativamente menor (p ≤ 0,01) en quienes llevaban trabajando más de 20 años (6,9; DE=1,9). Señalaron como sus principales consecuencias la puesta en peligro de la sostenibilidad del sistema (48,1%; IC95%: 41,2-54,9) y el potencial daño a los pacientes (32,1%; IC95%: 25,7-38,5) y como principales factores que contribuyen a su mantenimiento la acción de los propios pacientes (28%; IC95%: 22,6-35,0), la carga de trabajo (26,4%; IC95%: 20,3-32,5) y la falta de formación continuada (19,3%; IC95%: 13,9-24,7). No había diferencias significativas en las respuestas con ninguna variable sociodemográfica analizada. Las intervenciones clínicas, según los encuestados, que presentan un mayor grado de utilización inadecuada son la prescripción de antibióticos en procesos infecciosos de probable origen vírico, la periodicidad del cribado del cáncer de cuello uterino, el control estrecho mediante fármacos de la diabetes tipo II en pacientes 65 años y la utilización de benzodiacepinas, hipnóticos y antipsicóticos en pacientes ancianos o el uso de analgésicos en pacientes con hipertensión o insuficiencia renal. Conclusiones: La utilización de intervenciones inefectivas en atención primaria es apreciado como un problema muy relevante por los profesionales que trabajan en este ámbito; afectaría a muchos de los pacientes atendidos y a muchas de las prácticas actualmente realizadas en los centros de salud y podría estar poniendo en peligro la sostenibilidad del sistema sanitario y causando daños a los pacientes. Deberían llevarse a cabo programas de mejora centrados en ciertas intervenciones identificadas con un mayor nivel de uso inadecuado para reducir el impacto de este problema en atención primaria

Antibiotic susceptibility trend before and after long-term use of selective digestive decontamination: a 16 year ecological study

Objectives: The aim of this study was to compare antimicrobial susceptibility rates in a Spanish ICU before and after the introduction of selective digestive decontamination (SDD) and also to compare these with susceptibility data from other Spanish ICUs without SDD. Methods: We performed a retrospective study in the ICU of the University Hospital of Alava, where SDD was implemented in 2002. The SDD protocol consisted of a 2% mixture of gentamicin, colistin and amphotericin B applied on the buccal mucosa and a suspension of the same drugs in the gastrointestinal tract; additionally, for the first 3 days, systemic ceftriaxone was administered. From 1998 to 2013 we analysed the susceptibility rates for 48 antimicrobial/organism combinations. Interrupted time series using a linear dynamic model with SDD as an intervention was used. Data from other ICUs were obtained fromthe ENVIN-HELICS national registry. Results: Only amoxicillin/clavulanic acid against Escherichia coli and Proteus mirabilis, and a high concentration of gentamicin against Enterococcus faecalis, resulted in a significant decrease in the susceptibility rate after the implementation of SDD, with a drop of 20%, 27% and 32%, respectively. Compared with other Spanish ICUs without SDD, the susceptibility ratewas higher in the ICU of our hospital inmost cases.When itwas lower, differences were <10%, except for a high concentration of streptomycin against Enterococcus faecium, for which the difference was 19%. Conclusions: No relevant changes in the overall susceptibility rate after the implementation of SDD were detected. Susceptibility rates were not lower than those in the Spanish ICUs without SDD.This work was supported by the University of the Basque Country UPV/EHU (GIU17/32, PPG17/65)

Soluble platelet-endothelial cell adhesion molecule-1, a biomarker of ventilator-induced lung injury

Introduction: Endothelial cell injury is an important component of acute lung injury. Platelet-endothelial cell adhesion molecule-1 (PECAM1) is a transmembrane protein that connects endothelial cells to one another and can be detected as a soluble, truncated protein (sPECAM1) in serum. We hypothesized that injurious mechanical ventilation (MV) leads to shedding of PECAM1 from lung endothelial cells resulting in increasing sPECAM1 levels in the systemic circulation. Methods: We studied 36 Sprague–Dawley rats in two prospective, randomized, controlled studies (healthy and septic) using established animal models of ventilator-induced lung injury. Animals (n = 6 in each group) were randomized to spontaneous breathing or two MV strategies: low tidal volume (VT) (6 ml/kg) and high-VT (20 ml/kg) on 2 cmH2O of positive end-expiratory pressure (PEEP). In low-VT septic animals, 10 cmH2O of PEEP was applied. We performed pulmonary histological and physiological evaluation and measured lung PECAM1 protein content and serum sPECAM1 levels after four hours ventilation period. Results: High-VT MV caused severe lung injury in healthy and septic animals, and decreased lung PECAM1 protein content (P < 0.001). Animals on high-VT had a four- to six-fold increase of mean sPECAM1 serum levels than the unventilated counterpart (35.4 ± 10.4 versus 5.6 ± 1.7 ng/ml in healthy rats; 156.8 ± 47.6 versus 35.6 ± 12.6 ng/ml in septic rats) (P < 0.0001). Low-VT MV prevented these changes. Levels of sPECAM1 in healthy animals on high-VT MV paralleled the sPECAM1 levels of non-ventilated septic animals. Conclusions: Our findings suggest that circulating sPECAM1 may represent a promising biomarker for the detection and monitoring of ventilator-induced lung injury

Endotoxin-induced lung alveolar cell injury causes brain cell damage

Instituto de Salud Carlos III (ISCIII

Systemic Effects Induced by Hyperoxia in a Preclinical Model of Intra-abdominal Sepsis

Supplemental oxygen is a supportive treatment in patients with sepsis to balance tissue oxygen delivery and demand in the tissues. However, hyperoxia may induce some pathological effects. We sought to assess organ damage associated with hyperoxia and its correlation with the production of reactive oxygen species (ROS) in a preclinical model of intra-abdominal sepsis. For this purpose, sepsis was induced in male, Sprague-Dawley rats by cecal ligation and puncture (CLP). We randomly assigned experimental animals to three groups: control (healthy animals), septic (CLP), and sham-septic (surgical intervention without CLP). At 18 h after CLP, septic (n = 39), sham-septic (n = 16), and healthy (n = 24) animals were placed within a sealed Plexiglas cage and randomly distributed into four groups for continuous treatment with 21%, 40%, 60%, or 100% oxygen for 24 h. At the end of the experimental period, we evaluated serum levels of cytokines, organ damage biomarkers, histological examination of brain and lung tissue, and ROS production in each surviving animal. We found that high oxygen concentrations increased IL-6 and biomarkers of organ damage levels in septic animals, although no relevant histopathological lung or brain damage was observed. Healthy rats had an increase in IL-6 and aspartate aminotransferase at high oxygen concentration. IL-6 levels, but not ROS levels, are correlated with markers of organ damage. In our study, the use of high oxygen concentrations in a clinically relevant model of intra-abdominal sepsis was associated with enhanced inflammation and organ damage. These findings were unrelated to ROS release into circulation. Hyperoxia could exacerbate sepsis-induced inflammation, and it could be by itself detrimental. Our study highlights the need of developing safer thresholds for oxygen therapy

Ozone Eliminates SARS-CoV-2 from Difficult-to-Clean Office Supplies and Clinical Equipment.

Background: Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) continues to cause profound health, economic, and social problems worldwide. The management and disinfection of materials used daily in health centers and common working environments have prompted concerns about the control of coronavirus disease 2019 (COVID-19) infection risk. Ozone is a powerful oxidizing agent that has been widely used in disinfection processes for decades. The aim of this study was to assess the optimal conditions of ozone treatment for the elimination of heat-inactivated SARS-CoV-2 from office supplies (personal computer monitors, keyboards, and computer mice) and clinical equipment (continuous positive airway pressure tubes and personal protective equipment) that are difficult to clean. (2) Methods: The office supplies and clinical equipment were contaminated in an area of 1 cm2 with 1 × 104 viral units of a heat-inactivated SARS-CoV-2 strain, then treated with ozone using two different ozone devices: a specifically designed ozonation chamber (for low–medium ozone concentrations over large volumes) and a clinical ozone generator (for high ozone concentrations over small volumes). SARS-CoV-2 gene detection was carried out using quantitative real-time polymerase chain reaction (RT-qPCR). (3) Results: At high ozone concentrations over small surfaces, the ozone eliminated SARS-CoV-2 RNA in short time periods—i.e., 10 min (at 4000 ppm) or less. The optimum ozone concentration over large volumes was 90 ppm for 120 min in ambient conditions (24 °C and 60–75% relative humidity). (4) Conclusions: This study showed that the appropriate ozone concentration and exposure time eliminated heat-inactivated SARS-CoV-2 RNA from the surfaces of different widely used clinical and office supplies, decreasing their risk of transmission, and improving their reutilization. Ozone may provide an additional tool to control the spread of the COVID-19 pandemic.TRUEInstituto de Salud Carlos III, Madrid, Spain, and by the European Regional Development Funds (FEDER)Fundación Canaria del Instituto de Investigación Sanitaria de Canarias (FIISC), Las PalmasFundación Mapfre Guanarteme, Las PalmasGobierno de Canarias, Las Palmaspu

Cohort study protocol: Bioresource in Adult Infectious Diseases (BioAID)

Introduction: Infectious diseases have a major impact on morbidity and mortality in hospital. Microbial diagnosis remains elusive for most cases of suspected infection which impacts on the use of antibiotics. Rapid advances in genomic technologies combined with high-quality phenotypic data have great potential to improve the diagnosis, management and clinical outcomes of infectious diseases.  The aim of the Bioresource in Adult Infectious Diseases (BioAID) is to provide a platform for biomarker discovery, trials and clinical service developments in the field of infectious diseases, by establishing a registry linking clinical phenotype to microbial and biological samples in adult patients who attend hospital with suspected infection. Methods and analysis: BioAID is a cohort study which employs deferred consent to obtain an additional 2.5mL RNA blood sample from patients who attend the Emergency Department (ED) with suspected infection when they undergo peripheral blood culture sampling.  Clinical data and additional biological samples including DNA, serum and microbial isolates are obtained from BioAID participants during hospital admission.  Participants are also asked to consent to be recalled for future studies. BioAID aims to recruit 10,000 patients from 5-8 sites across England.  Since February 2014 >4000 individuals have been recruited to the study.  The final cohort will be characterised using descriptive statistics including information on the number of cases that can be linked to biological and microbial samples to support future research studies. Ethical approval and section 251 exemption have been obtained for BioAID researchers to seek deferred consent from patients from whom a RNA specimen has been collected. Samples and meta-data obtained through BioAID will be made available to researchers worldwide following submission of an application form and research protocol.   Conclusions: BioAID will support a range of study designs spanning discovery science, biomarker validation, disease pathogenesis and epidemiological analyses of clinical infection syndromes

Circulando hacia la seguridad del paciente: realidad y deseo

Resumen: Objetivo: Valorar diferencias entre necesidad e implementación de prácticas seguras recomendadas para la seguridad del paciente y utilidad del uso de señales de tráfico para promover su implementación. Método: El estudio constó de dos fases: 1) revisión de recomendaciones sobre prácticas seguras de diferentes organizaciones y 2) encuesta a una muestra de oportunidad de profesionales del ámbito asistencial, organizativo y académico de la seguridad del paciente de España y Latinoamérica para evaluar necesidad y la implementación percibida de las prácticas seguras y la utilidad de las señales para tal fin. Resultados: Se recibieron 365 cuestionarios. Todas las prácticas seguras identificadas fueron valoradas como necesarias (media y límite inferior del intervalo de confianza por encima de 3 sobre 5 puntos). Sin embargo, la implementación se valoró como insuficiente en seis de ellas: escritura ilegible, conciliación de medicación, estandarización de comunicación, sistemas de alerta rápida, aplicación de procedimientos por profesionales o equipos entrenados, y cumplimiento de voluntades del paciente al final de la vida. Mejorar cumplimiento de la higiene de manos, aplicación de precauciones de barrera, asegurar la identificación correcta de los pacientes y utilizar listados de verificación fueron las cuatro prácticas en las que más del 75% de los encuestados encuentran mayor grado de consenso sobre la utilidad de las señales de tráfico para mejorar su implementación. Conclusiones: Las diferencias entre necesidad percibida e implementación real de las prácticas seguras consideradas indican áreas de mejora. El lenguaje común de las señales de tráfico es un instrumento sencillo para mejorar su cumplimiento. Abstract: Objective: To evaluate differences between the need and degree of implementation of safe practices recommended for patient safety and to check the usefulness of traffic sign iconicity to promote their implementation. Method: The study was developed in two stages: 1) review of safe practices recommended by different organizations and 2) a survey to assess the perceptions for the need and implementation of them and the usefulness of signs to improve their implementation. The sample consisted of professionals from Spain and Latin America working in healthcare settings and in the academic field related to patient safety. Results: 365 questionnaires were collected. All safe practices included were considered necessary (mean and lower limit of confidence interval over 3 out of 5 points). However, in six of the patient safety practices evaluated the implementation was considered insufficient: illegible handwriting, medication reconciliation, standardization of communication systems, early warning systems, procedures performed or equipment used only by trained people, and compliance with patient preferences at the end of life. Improve compliance of with hand hygiene and barrier precautions to prevent infections, ensure the correct identification of patients and the use of checklists are the four practices in which more than 75% of respondents found a high degree of consensus on the usefulness of traffic sings to broaden their use. Conclusion: The differences between perceived need and actual implementation in some safe practices indicate areas for improvement in patient safety. With this aim, the common language and the iconicity of traffic signs could constitute a simple instrument to improve compliance with safe practices for patient safety. Palabras clave: Seguridad del paciente, Prácticas clínicas seguras, Gestión del riesgo, Yatrogenia, Keywords: Patient safety, Safe clinical practices, Risk management, Iatrogenic diseas