EBUS

EBUS (EndoBronchial Ultrasound) or Ecobronchoscopy is a minimally invasive technique that uses Ultrasound, at the same time as endoscopic vision, to assess mediastinal alterations, allowing fine needle puncture. The EBUS allows a precise diagnosis in real time, since the samples obtained are analyzed in situ by the Pathological Anatomy Service. In our hospital, this technique has been carried out since July 2019, having performed more than 100 procedures at the present time. The patient is evaluated in our Pre-Anesthesia Consultation, where airway exploration is performed, assessment of the patient's cardiopulmonary situation, hemostasis, and the patient is instructed to withdraw or maintain his medication, in order to minimize the risk. of complications. In our center the anesthetic technique of choice is General Anesthesia (TIVA-TCI), with the use of Neuromuscular Relaxant. We proceed to the placement of a Laryngeal Mask that will allow us the correct ventilation of the patient and the entrance of the EBUS, without interfering with the vision of the adenopathies/masses that must be biopsied. The procedure is performed with standard monitoring and BIS and the patient, if there are no complications, is extubated in the Techniques Room. Most of our patients are outpatients, being transferred after the EBUS to the PACU, where after staying 3-4 hours they are discharged.El EBUS (EndoBronchial Ultrasound) o Ecobroncoscopia es una técnica minimamente invasiva que utiliza Ultrasonidos, al mismo tiempo que la visión endoscópica, para valoración de alteraciones mediastínicas, permitiendo su punción con aguja fina. El EBUS permite un diagnóstico preciso en tiempo real, ya que las muestras obtenidas son analizadas in situ por el Servicio de Anatomía Patológica.  En nuestro hospital esta tècnica se lleva realizando desde Julio de 2019 habiendo realizado en el momento actual mas de 100 procedimientos. El paciente es valorado en nuestra Consulta de Preanestesia, donde se realiza exploración de la vía aérea, valoración de la situación cardiopulmonar, de la hemostasia del paciente y se indica al paciente la retirada o mantenimeinto de su medicación, con el fin de minimizar el riesgo de complicaciones. En nuestro centro la técnica anestésica de elección es la Anestesia General (TIVA-TCI) , con la utilización de Relajante Neuromuscular. Se procede a la colocación de una Mascarilla Laringea que nos va a permitir la corecta ventilación del paciente y la entrada del EBUS, sin interferir con la visión de las adenopatías/masas que deben de ser biopsiadas. El procedimiento se realiza con monitorizacón standart y BIS y el paciente, si no hay complicaciones , es extubado en la Sala de Técnicas. La mayoría de nuestros pacientes son Ambulatorios, siendo trasladados tras el EBUS a la URPA, donde tras permanecer 3-4 horas son dados de Alta

Reporte de sostenibilidad como herramienta de gestión - CIME Ingenieros S.R.L.

CIME Ingenieros es una empresa con más de 30 años de experiencia en el sector industrial, enfocados prioritariamente en el sector de hidrocarburos. Las principales actividades que desarrolla están orientadas al mantenimiento, fabricación de tanques de almacenamiento de hidrocarburo, montaje e instalación de equipos electromecánicos, estructuras metálicas y de gas natural, apuntando a cumplir estándares de calidad , seguridad, salud ocupacional y medio ambiente, así como también, las buenas prácticas de gestión de proyectos. El éxito que ha logrado CIME Ingenieros con el transcurrir de los años se debe a la prestación de un servicio de calidad y al cumplimiento con los plazos de entrega en la implementación de los proyectos, sin tener ninguna observación de actos de desconfianza; esto ha generado la fidelización de los clientes con los cuales la empresa mantiene relación hasta el día de hoy. Si bien es cierto, estos fuertes vínculos comerciales se generaron con los primeros clientes en el inicio del ciclo de vida de la empresa, aún no se ha podido generar un crecimiento sostenido. El principal problema que se ha identificado es la falta de implementación de un plan de Gobierno Corporativo debido a que no existen lineamientos y normas organizacionales adecuadas que, a su vez respalden y soporten las funcionalidades actuales requeridas para el crecimiento sostenible de la empresa. Por tal motivo, el presente trabajo de investigación tiene como finalidad mostrar los problemas que está atravesando la empresa en la actualidad y sus posibles alternativas de solución. Para lograr ello, se ha establecido realizar un análisis interno y externo de la organización para tener bien definido el entorno en el que se desarrolla CIME Ingenieros, sus stakeholders y sus posibilidades de mantenerse en el tiempo como una empresa sostenible. Asimismo, se ha realizado un análisis cualitativo y cuantitativo de la organización, en función a determinar cómo se encuentra evolucionando en el tiempo y como va afrontando sus necesidades y las coyunturas sociales y políticas que atraviesa nuestro país. Debemos indicar que, como resultado de los análisis cualitativos y cuantitativos, se identifican los problemas claves de la organización y sus orígenes, así como también, se plantean alternativas de solución, las cuales pueden ser implementadas por la organización. La presente tesis plantea implementar un adecuado plan de gobierno corporativo, cuyo concepto hace referencia al conjunto de principios, normas y procedimientos que forman parte del funcionamiento y la estructura de la toma de decisiones en la empresa para la generación de valor. En este punto, se puede evidenciar que la empresa tiene una formación familiar y que, a lo largo de su evolución, no han tomado en cuenta la implementación de este sistema, pues se tiene la idea de que estos lineamientos solo lo deben tener las grandes empresas, dejando de lado muchas oportunidades que tiene la empresa para tener un crecimiento sostenido. La implementación de los principios de sostenibilidad ayuda a la organización a reducir costos, incrementar su productividad, tener nuevas oportunidades de negocios y crear nuevos empleos y genera una empresa más competitiva, por lo que realizar esta implementación para CIME Ingenieros, en la actualidad, es más que necesaria.CIME Ingenieros is a company which has over 30 years of experience in the industrial sector, focusing primarily on the hydrocarbons sector. The main activities are oriented to maintenance, manufacture of hydrocarbon storage tanks, assembly and installation of electromechanical equipment, metal structures and natural gas, aiming to meet standards of quality, safety, occupational health and environment, as well as good project management practices. The success that CIME Ingenieros has achieved over the years is due to the provision of a quality service and compliance with delivery times in the project’s implementation, without any observation of acts of mistrust; this has generated customer loyalty with which the company maintains a relationship until now. Although it is true that these strong trade links were generated with the first customers at the beginning of the life cycle of the company, it has not yet been possible to generate sustained growth. The main problem that has been identified is the lack of implementation of a Corporate Governance plan due to the fact that there are no adequate organizational guidelines and norms that, in turn, endorse and support the current functionalities required for the sustainable growth of the company. For this reason, the purpose of this research work is to reveal the problems that the company is currently going through and its possible solution alternatives. To achieve this, an internal and external analysis of the organization has been established in order to clearly define the environment in which CIME Ingenieros develops, its stakeholders and its possibilities of maintaining itself over time as a sustainable company. Likewise, a qualitative and quantitative analysis of the organization has been carried out, in order to determine how it is evolving over time and how it is facing its needs as well as the social and political conjunctures that our country is going through. We must point out that, as a result of the qualitative and quantitative analyses, the key problems of the organization and its origins are identified, as well as alternative solutions, which can be implemented by CIME Ingenieros. This thesis proposes to implement an appropriate corporate governance plan, whose concept refers to the set of principles, standards and procedures that are part of the performance and structure of decision-making in the company to generate value. At this point, it can be evidenced that the company has a family background and that, throughout its evolution, have not considered the implementation of this system, because it has the idea that these guidelines should only have large companies, leaving aside many opportunities that the company has to achieve sustained growth. Being sustainable helps the organization to reduce costs, increase productivity, have new business opportunities as well as create new jobs and generate a better competitive company, so this implementation for CIME Ingenieros is more necessary than ever.Tesi

Efficacy and Safety of Oral Fosfomycin for Asymptomatic Bacteriuria in Kidney Transplant Recipients: Results from a Spanish Multicenter Cohort

Current guidelines recommend against systematic screening for or treating asymptomatic bacteriuria (AB) among kidney transplant (KT) recipients, although the evidence regarding episodes occurring early after transplantation or in the presence of anatomical abnormalities is inconclusive. Oral fosfomycin may constitute a good option for the treatment of posttransplant AB, particularly due to the emergence of multidrug-resistant (MDR) uropathogens. Available clinical evidence supporting its use in this specific setting, however, remains scarce. We performed a retrospective study in 14 Spanish institutions from January 2005 to December 2017. Overall, 137 episodes of AB diagnosed in 133 KT recipients treated with oral fosfomycin (calcium and trometamol salts) with a test-of-cure urine culture within the first 30 days were included. Median time from transplantation to diagnosis was 3.1 months (interquartile range [IQR], 1.1 to 10.5). Most episodes (96.4% [132/137]) were caused by Gram-negative bacteria (GNB), and 56.9% (78/137) were categorized as MDR (extended?spectrum ??lactamase?producing Enterobacterales [20.4%] and carbapenem?resistant GNB [2.9%]). Rate of microbiological failure at month 1 was 40.1% (95% confidence interval [CI], 31.9% to 48.9%) for the whole cohort and 42.3% (95% CI, 31.2% to 54.0%) for episodes due to MDR pathogens. Previous urinary tract infection (odds ratio [OR], 2.42; 95% CI, 1.11 to 5.29; P value = 0.027) and use of fosfomycin as salvage therapy (OR, 8.31; 95% CI, 1.67 to 41.35; P value = 0.010) were predictors of microbiological failure. No severe treatment-related adverse events were detected. Oral fosfomycin appears to be a suitable and safe alternative for the treatment (if indicated) of AB after KT, including those episodes due to MDR uropathogens.ACKNOWLEDGMENTS This study was supported by Plan Nacional de I+D+i 2013‐2016 and Instituto de Salud Carlos III (ISCIII), Subdirección General de Redes y Centros de Investigación Cooperativa, Ministry of Science and Innovation, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), and Spanish Network for Research in Renal Diseases (REDInREN RD16/0009) and cofinanced by the European Development Regional Fund entitled A way to achieve Europe. M.F.-R. holds a research contract (Miguel Servet, CP18/00073), from the Spanish Ministry of Science and Innovation, ISCIII. Funding sources were not involved in the study design and conduction, data analysis, or manuscript preparation

Oral fosfomycin for the treatment of lower urinary tract infections among kidney transplant recipients—Results of a Spanish multicenter cohort

Preliminary results of this study were presented at the 29th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), held in Amsterdam, The Netherlands, from 13 to 16 April, 2019 (oral communication O‐0699).Oral fosfomycin may constitute an alternative for the treatment of lower urinary tract infections (UTIs) in kidney transplant recipients (KTRs), particularly in view of recent safety concerns with fluroquinolones. Specific data on the efficacy and safety of fosfomycin in KTR are scarce. We performed a retrospective study in 14 Spanish hospitals including KTRs treated with oral fosfomycin (calcium and trometamol salts) for posttransplant cystitis between January 2005 and December 2017. A total of 133 KTRs developed 143 episodes of cystitis. Most episodes (131 [91.6%]) were produced by gram‐negative bacilli (GNB), and 78 (54.5%) were categorized as multidrug resistant (including extended‐spectrum β‐lactamase‐producing Enterobacteriaceae [14%] or carbapenem‐resistant GNB [3.5%]). A median daily dose of 1.5 g of fosfomycin (interquartile range [IQR]: 1.5‐2) was administered for a median of 7 days (IQR: 3‐10). Clinical cure (remission of UTI‐attributable symptoms at the end of therapy) was achieved in 83.9% (120/143) episodes. Among those episodes with follow‐up urine culture, microbiological cure at month 1 was achieved in 70.2% (59/84) episodes. Percutaneous nephrostomy was associated with a lower probability of clinical cure (adjusted odds ratio: 10.50; 95% confidence interval: 0.98‐112.29; P = 0.052). In conclusion, fosfomycin is an effective orally available alternative for treating cystitis among KTRs.This study was supported by Plan Nacional de I+D+i 2013‐2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016)—cofinanced by the European Development Regional Fund “A way to achieve Europe”; the Group for Study of Infection in Transplantation and the Immunocompromised Host (GESITRA‐IC) of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC); and the Spanish Network for Research in Renal Diseases (REDInREN RD16/0009). MFR holds a research contract “Miguel Servet” (CP 18/00073) from the Spanish Ministry of Science, Innovation and Universities, Instituto de Salud Carlos III

Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19

Background: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. Objectives: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). Methods: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. Results: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom were discharged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176-3.037), age 1200/mm(3) (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A total of 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). Conclusion: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality

Efficacy and Safety of Oral Fosfomycin for Asymptomatic Bacteriuria in Kidney Transplant Recipients: Results from a Spanish Multicenter Cohort

Current guidelines recommend against systematic screening for or treating asymptomatic bacteriuria (AB) among kidney transplant (KT) recipients, although the evidence regarding episodes occurring early after transplantation or in the presence of anatomical abnormalities is inconclusive. Oral fosfomycin may constitute a good option for the treatment of posttransplant AB, particularly due to the emergence of multidrug-resistant (MDR) uropathogens. Available clinical evidence supporting its use in this specific setting, however, remains scarce. We performed a retrospective study in 14 Spanish institutions from January 2005 to December 2017. Overall, 137 episodes of AB diagnosed in 133 KT recipients treated with oral fosfomycin (calcium and trometamol salts) with a test-of-cure urine culture within the first 30 days were included. Median time from transplantation to diagnosis was 3.1 months (interquartile range [IQR], 1.1 to 10.5). Most episodes (96.4% [132/137]) were caused by Gram-negative bacteria (GNB), and 56.9% (78/137) were categorized as MDR (extended‐spectrum β‐lactamase‐producing Enterobacterales [20.4%] and carbapenem‐resistant GNB [2.9%]). Rate of microbiological failure at month 1 was 40.1% (95% confidence interval [CI], 31.9% to 48.9%) for the whole cohort and 42.3% (95% CI, 31.2% to 54.0%) for episodes due to MDR pathogens. Previous urinary tract infection (odds ratio [OR], 2.42; 95% CI, 1.11 to 5.29; P value = 0.027) and use of fosfomycin as salvage therapy (OR, 8.31; 95% CI, 1.67 to 41.35; P value = 0.010) were predictors of microbiological failure. No severe treatment-related adverse events were detected. Oral fosfomycin appears to be a suitable and safe alternative for the treatment (if indicated) of AB after KT, including those episodes due to MDR uropathogens.This study was supported by Plan Nacional de I+D+i 2013‐2016 and Instituto de Salud Carlos III (ISCIII), Subdirección General de Redes y Centros de Investigación Cooperativa, Ministry of Science and Innovation, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), and Spanish Network for Research in Renal Diseases (REDInREN RD16/0009) and cofinanced by the European Development Regional Fund entitled A way to achieve Europe. M.F.-R. holds a research contract (Miguel Servet, CP18/00073), from the Spanish Ministry of Science and Innovation, ISCIII.Peer reviewe

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

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

Métodos de medición de las desigualdades de salud

RESUMEN La medición de las desigualdades en el campo de la salud es una condición indispensable para avanzar en la mejoría de la situación de salud de la Región, donde el análisis de los valores medios ha dejado de ser suficiente. Este tipo de análisis es una herramienta fundamental para la acción en busca de una mayor equidad en salud. Existen diferentes métodos de medición y niveles de complejidad cuya elección depende del objetivo del estudio. Este artículo tiene como objetivo familiarizar a los profesionales de la salud y a las instancias decisorias con los aspectos metodológicos de la medición y el análisis simple de las desigualdades en el campo de la salud, utilizando datos básicos registrados con regularidad y agregados por unidades geopolíticas. Se presenta la forma de calcular los siguientes indicadores y se comentan sus ventajas y desventajas: la razón y la diferencia de tasas, el índice de efecto, el riesgo atribuible poblacional, el índice de disimilitud, el índice de desigualdad de la pendiente y el índice relativo de desigualdad, el coeficiente de Gini y el índice de concentración. Los métodos presentados son aplicables a la medición de las desigualdades de diferentes tipos y a distintos niveles de análisis