Atención en la agonía

La mayoría de los pacientes en situación terminal pasan por una fase de deterioro que precede en unos días a su fallecimiento y se denomina agonía. El reconocimiento de que una persona está entrando en esta fase es fundamental para adecuar el plan de cuidados del enfermo y su familia, enfatizando en el confort y los cuidados esenciales. La atención a los familiares debe ser una actividad central de la asistencia en esta fase de la enfermedad. Debemos informar claramente de la situación, tratando de anticipar la probable sintomatología que puede tener el paciente, y como y cuando se va a producir la muerte. Se debe fomentar una actitud activa de los familiares y facilitar apoyo emocional. El plan de cuidados en esta fase debe incluir las medidas ambientales y físicas y el tratamiento farmacológico necesario para controlar adecuadamente la sintomatología. El resto de los tratamientos farmacológicos deben ser retirados. Generalmente la vía de elección en la administración de fármacos es la subcutánea. La nutrición e hidratación no están generalmente indicadas en esta fase salvo consideraciones especiales. En algunas ocasiones la sintomatología del paciente en la fase agónica no puede controlarse con los tratamientos habituales y debemos recurrir a la sedación. La sedación paliativa se define como “el uso de fármacos específicamente sedantes para reducir un sufrimiento intolerable, derivado de síntomas refractarios, mediante la disminución del nivel de consciencia del paciente”. La indicación de sedación paliativa debe cumplir una serie de garantías éticas y una adecuada realización y monitorización del tratamiento.Most terminally-ill patients pass through a phase of deterioration that precedes, by a few days, their death. Making the diagnosis of dying phase is key to ensuring that the patient and his or her family receives the best possible care and eventually experiences a good death. Care of the families should be a central activity of health teams in this phase. We should inform clearly of the situation, trying to anticipate symptoms and time, as well as circumstances, to death. We should encourage an active attitude of the family and adequate emotional support. Care plan should include non-pharmacological and pharmacological approach to achieve symptom control. Usually subcutaneous route is the best route to administrate drugs in this phase. Nutrition and fluids should not be offered to imminently dying patients unless it is considered likely that the benefit will outweigh the harm. Sometimes, when is no possible to relieve symptoms in the last days of life with available drugs, we can use palliative sedation therapy. Palliative sedation is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness. The indication of palliative sedation should follow systematic and inclusive processes that include ethical considerations, drug selection and monitoring of patients

Eficiencia de las unidades propias vs. franquiciadas. Estudio según el nivel de internacionalización del franquiciador

El objetivo de este trabajo, centrado en el sistema de franquicia español, gira en torno a las siguientes cuestiones: ¿Qué unidades de las redes de franquicia son más eficientes: las propias o las franquiciadas? ¿influye el nivel de internacionalización del franquiciador en la eficiencia de las unidades propias vs. franquiciadas? Para responder a estos interrogantes, no resueltos en la literatura científica sobre franquicia, se desarrolla un marco teórico y se proponen una serie de hipótesis empleando los fundamentos de la Teoría de la Agencia, la Teoría de las Escasez de Recursos y la Teoría de las Señales. En los análisis, a partir de los datos de la totalidad de la población de franquicias en 2015 -1.232 franquicias-, se emplean tres indicadores de eficiencia: ventas/unidad (V/U), ventas/empleado (V/E) y empleados/unidad (E/U), dividiéndose la información en dos subgrupos: unidades propias (UP) y unidades franquiciadas (UF). Test de medias de carácter no paramétrico se emplean para la comparación de los dos grupos. Los resultados demuestran la mayor eficiencia de las UP frente a las UF, siendo estos resultados generalizables a todo el sistema de franquicia español y ello con independencia del nivel de internacionalización de la cadena franquiciadora.The aim of this paper, focused on the Spanish franchise system, centers on the following questions: What units franchise networks are more efficient: one's own or franchised? Does the level of internationalization of the franchisor influence the efficiency of the own units vs. franchisees? To answer these questions, unresolved in the scientific literature on franchise, a theoretical framework is developed and a number of hypotheses are proposed using the fundamentals of Agency Theory, Resource Scarcity Theory and Signaling Theory. In the analysis, data from the total population of franchises in 2015 -1.232 franchisee - three efficiency indicators are used: sales/unit (V/U), sales/employee (V/E) and employees/unit (E/U), dividing the information into two subgroups: own units (UP) and franchised units (UF). Means test nonparametric character are used for comparison of two groups. The results show the increased efficiency of UP against the UF, and these results are generalizable to the total Spanish franchising system and this regardless of the level of internationalization of the franchising chain

Residents’ Insights on Their Local Food Environment and Dietary Behaviors: A Cross-City Comparison Using Photovoice in Spain

Perceptions of local food environments and the ability of citizens to engage in participatory research may vary, even if participants share similar cultural and socioeconomic contexts. In this study, we aimed to describe participants’ narratives about their local food environment in two cities in Spain. We used the participatory methodology of Photovoice to engage participants in Madrid (n = 24) and Bilbao (n = 17) who took and discussed photographs about their local food environment (Madrid; n = 163 and Bilbao; n = 70). Common themes emerged across both cities (food insecurity, poverty, use of public spaces for eating and social gathering, cultural diversity and overconsumption of unhealthy foods); however, in Bilbao citizens perceived that there was sufficient availability of healthy foods despite that living in impoverished communities. Photovoice was a useful tool to engage participating citizens to improve their local food environments in both cities. This new approach allowed for a photovoice cross-city comparison that could be useful to fully understand the complexity and diversity of residents’ perceptions regardless of their place of residence.This research was funded by The European Research Council under the European Union’s Seventh Framework Programme (FP7/2007–2013/ERC Starting Grant Heart Healthy Hoods Agreement no. 336893) and the University of the Basque Country (16/35, 2016). “The Photovoice project in Madrid was co-funded by an “Ignacio Hernando de Llarramendi” research grant 2014 of the MAPFRE Foundation”

El sistema de franquicia español: un análisis de eficiencia

Este trabajo está centrado en el sistema de franquicia español y los sectores que lo conforman distinguiendo tres niveles de agrupación: Comercio Minorista, Hostelería/Restauración y Servicios. En primer lugar, realizamos un análisis global del sistema de franquicia español y su evolución. A continuación, se analizan y comparan las diferencias de resultados por sectores, comprobando si las diferencias son estadísticamente significativas. En tercer lugar, se muestra cuál de los dos tipos de unidades (propias o franquiciadas) empleadas por las redes de franquicias son más eficientes, mostrándose los resultados a favor de las unidades propias.This work is focused on the Spanish franchise system and the sectors that make it up, distinguishing three levels of grouping: Retail, Hotels/Restaurants and Services. First, we perform an overall analysis of the Spanish franchise system and its evolution. Next, we analyze and compare the differences of results by sector, checking if the differences are statistically significant. Third, it shows which of the two types of units (own or franchised) used by franchise networks are more efficient, showing the results in favor of the own unit

The Genotype of the Donor for the (GT)n Polymorphism in the Promoter/Enhancer of FOXP3 Is Associated with the Development of Severe Acute GVHD but Does Not Affect the GVL Effect after Myeloablative HLA-Identical Allogeneic Stem Cell Transplantation

The FOXP3 gene encodes for a protein (Foxp3) involved in the development and functional activity of regulatory T cells (CD4+/CD25+/Foxp3+), which exert regulatory and suppressive roles over the immune system. After allogeneic stem cell transplantation, regulatory T cells are known to mitigate graft versus host disease while probably maintaining a graft versus leukemia effect. Short alleles (≤(GT)15) for the (GT)n polymorphism in the promoter/enhancer of FOXP3 are associated with a higher expression of FOXP3, and hypothetically with an increase of regulatory T cell activity. This polymorphism has been related to the development of auto- or alloimmune conditions including type 1 diabetes or graft rejection in renal transplant recipients. However, its impact in the allo-transplant setting has not been analyzed. In the present study, which includes 252 myeloablative HLA-identical allo-transplants, multivariate analysis revealed a lower incidence of grade III-IV acute graft versus host disease (GVHD) in patients transplanted from donors harboring short alleles (OR = 0.26, CI 0.08-0.82, p = 0.021); without affecting chronic GVHD or graft versus leukemia effect, since cumulative incidence of relapse, event free survival and overall survival rates are similar in both groups of patients

Predicting Clinical Outcome with Phenotypic Clusters in COVID-19 Pneumonia: An Analysis of 12,066 Hospitalized Patients from the Spanish Registry SEMI-COVID-19

(1) Background: Different clinical presentations in COVID-19 are described to date, from mild to severe cases. This study aims to identify different clinical phenotypes in COVID-19 pneumonia using cluster analysis and to assess the prognostic impact among identified clusters in such patients. (2) Methods: Cluster analysis including 11 phenotypic variables was performed in a large cohort of 12,066 COVID-19 patients, collected and followed-up from 1 March to 31 July 2020, from the nationwide Spanish Society of Internal Medicine (SEMI)-COVID-19 Registry. (3) Results: Of the total of 12,066 patients included in the study, most were males (7052, 58.5%) and Caucasian (10,635, 89.5%), with a mean age at diagnosis of 67 years (standard deviation (SD) 16). The main pre-admission comorbidities were arterial hypertension (6030, 50%), hyperlipidemia (4741, 39.4%) and diabetes mellitus (2309, 19.2%). The average number of days from COVID-19 symptom onset to hospital admission was 6.7 (SD 7). The triad of fever, cough, and dyspnea was present almost uniformly in all 4 clinical phenotypes identified by clustering. Cluster C1 (8737 patients, 72.4%) was the largest, and comprised patients with the triad alone. Cluster C2 (1196 patients, 9.9%) also presented with ageusia and anosmia; cluster C3 (880 patients, 7.3%) also had arthromyalgia, headache, and sore throat; and cluster C4 (1253 patients, 10.4%) also manifested with diarrhea, vomiting, and abdominal pain. Compared to each other, cluster C1 presented the highest in-hospital mortality (24.1% vs. 4.3% vs. 14.7% vs. 18.6%; p 20 bpm, lower PaO2/FiO2 at admission, higher levels of C-reactive protein (CRP) and lactate dehydrogenase (LDH), and the phenotypic cluster as independent factors for in-hospital death. (4) Conclusions: The present study identified 4 phenotypic clusters in patients with COVID-19 pneumonia, which predicted the in-hospital prognosis of clinical outcomes

Healthcare workers hospitalized due to COVID-19 have no higher risk of death than general population. Data from the Spanish SEMI-COVID-19 Registry

Aim To determine whether healthcare workers (HCW) hospitalized in Spain due to COVID-19 have a worse prognosis than non-healthcare workers (NHCW). Methods Observational cohort study based on the SEMI-COVID-19 Registry, a nationwide registry that collects sociodemographic, clinical, laboratory, and treatment data on patients hospitalised with COVID-19 in Spain. Patients aged 20-65 years were selected. A multivariate logistic regression model was performed to identify factors associated with mortality. Results As of 22 May 2020, 4393 patients were included, of whom 419 (9.5%) were HCW. Median (interquartile range) age of HCW was 52 (15) years and 62.4% were women. Prevalence of comorbidities and severe radiological findings upon admission were less frequent in HCW. There were no difference in need of respiratory support and admission to intensive care unit, but occurrence of sepsis and in-hospital mortality was lower in HCW (1.7% vs. 3.9%; p = 0.024 and 0.7% vs. 4.8%; p<0.001 respectively). Age, male sex and comorbidity, were independently associated with higher in-hospital mortality and healthcare working with lower mortality (OR 0.211, 95%CI 0.067-0.667, p = 0.008). 30-days survival was higher in HCW (0.968 vs. 0.851 p<0.001). Conclusions Hospitalized COVID-19 HCW had fewer comorbidities and a better prognosis than NHCW. Our results suggest that professional exposure to COVID-19 in HCW does not carry more clinical severity nor mortality

Association Between Preexisting Versus Newly Identified Atrial Fibrillation and Outcomes of Patients With Acute Pulmonary Embolism

Background Atrial fibrillation (AF) may exist before or occur early in the course of pulmonary embolism (PE). We determined the PE outcomes based on the presence and timing of AF. Methods and Results Using the data from a multicenter PE registry, we identified 3 groups: (1) those with preexisting AF, (2) patients with new AF within 2 days from acute PE (incident AF), and (3) patients without AF. We assessed the 90-day and 1-year risk of mortality and stroke in patients with AF, compared with those without AF (reference group). Among 16 497 patients with PE, 792 had preexisting AF. These patients had increased odds of 90-day all-cause (odds ratio [OR], 2.81; 95% CI, 2.33-3.38) and PE-related mortality (OR, 2.38; 95% CI, 1.37-4.14) and increased 1-year hazard for ischemic stroke (hazard ratio, 5.48; 95% CI, 3.10-9.69) compared with those without AF. After multivariable adjustment, preexisting AF was associated with significantly increased odds of all-cause mortality (OR, 1.91; 95% CI, 1.57-2.32) but not PE-related mortality (OR, 1.50; 95% CI, 0.85-2.66). Among 16 497 patients with PE, 445 developed new incident AF within 2 days of acute PE. Incident AF was associated with increased odds of 90-day all-cause (OR, 2.28; 95% CI, 1.75-2.97) and PE-related (OR, 3.64; 95% CI, 2.01-6.59) mortality but not stroke. Findings were similar in multivariable analyses. Conclusions In patients with acute symptomatic PE, both preexisting AF and incident AF predict adverse clinical outcomes. The type of adverse outcomes may differ depending on the timing of AF onset.info:eu-repo/semantics/publishedVersio

Diverse Large HIV-1 Non-subtype B Clusters Are Spreading Among Men Who Have Sex With Men in Spain

In Western Europe, the HIV-1 epidemic among men who have sex with men (MSM) is dominated by subtype B. However, recently, other genetic forms have been reported to circulate in this population, as evidenced by their grouping in clusters predominantly comprising European individuals. Here we describe four large HIV-1 non-subtype B clusters spreading among MSM in Spain. Samples were collected in 9 regions. A pol fragment was amplified from plasma RNA or blood-extracted DNA. Phylogenetic analyses were performed via maximum likelihood, including database sequences of the same genetic forms as the identified clusters. Times and locations of the most recent common ancestors (MRCA) of clusters were estimated with a Bayesian method. Five large non-subtype B clusters associated with MSM were identified. The largest one, of F1 subtype, was reported previously. The other four were of CRF02_AG (CRF02_1; n = 115) and subtypes A1 (A1_1; n = 66), F1 (F1_3; n = 36), and C (C_7; n = 17). Most individuals belonging to them had been diagnosed of HIV-1 infection in the last 10 years. Each cluster comprised viruses from 3 to 8 Spanish regions and also comprised or was related to viruses from other countries: CRF02_1 comprised a Japanese subcluster and viruses from 8 other countries from Western Europe, Asia, and South America; A1_1 comprised viruses from Portugal, United Kingom, and United States, and was related to the A1 strain circulating in Greece, Albania and Cyprus; F1_3 was related to viruses from Romania; and C_7 comprised viruses from Portugal and was related to a virus from Mozambique. A subcluster within CRF02_1 was associated with heterosexual transmission. Near full-length genomes of each cluster were of uniform genetic form. Times of MRCAs of CRF02_1, A1_1, F1_3, and C_7 were estimated around 1986, 1989, 2013, and 1983, respectively. MRCA locations for CRF02_1 and A1_1 were uncertain (however initial expansions in Spain in Madrid and Vigo, respectively, were estimated) and were most probable in Bilbao, Spain, for F1_3 and Portugal for C_7. These results show that the HIV-1 epidemic among MSM in Spain is becoming increasingly diverse through the expansion of diverse non-subtype B clusters, comprising or related to viruses circulating in other countries

Efectividad de un equipo de cuidados paliativos en los últimos días de vida

Tesis doctoral inédta leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina. Fecha de lectura: 1 de Octubre de 2013