Cambios en el patrón de uso de los servicios de urgencias en un complejo hospitalario terciario español sobresaturado durante la pandemia de COVID-19

Background and objectives: To analyze the effects of COVID-19 in the pattern of use (number of admissions, hospitalizations, hospitalization ratio, and classification by priorities) of Emergency Departments (EDs) of one tertiary referral hospital. Methods: Retrospective, observational and single-center study, carried on in the EDs of Virgen de las Nieves Hospital Complex (Granada, Spain). The information was collected from the three hospitals which belong to the Virgen de las Nieves Hospital complex (i.e. the General Hospital, GH; the Children’s Hospital, CH; and the Neuro-Trauma Hospital, NTH) from February 1st to July 31st, 2019, and 2020. Results: In the period under analysis, there were 71236 admissions compared with 118382 in the same period in 2019, which means an overall reduction of 38.83%. Considering the hospitalizations, there were 6841 compared with 7648 (2020 and 2019, respectively) which gives an overall reduction of 10.55%. The distribution of the priorities did not show a defined pattern; while CH and NTH’s EDs showed clear changes in their distribution, no notable changes were observed in GH’s ED. Conclusion: The Covid-19 Pandemic changed dramatically the pattern of ED referral in our tertiary referral hospital. A noticeable reduction of admissions and hospitalizations were reported, together with a pronounced increase in the hospitalization ratio that in some cases reached almost 50%. This could be explaining for many reasons, such as the fear of contagion and the lockdown that presumably caused a decrease in the less-severe cases attended. Possibly, the effects of COVID-19 may have been indirectly influenced by the health care system of each country. The COVID-19 pandemic constitutes one of the greatest challenges in modern medicine, understanding better these changes and the impact that COVID-19 has caused on pattern of use of EDs will probably lead us to manage and use better our public health systems in the future.Antecedentes y objetivos: Analizar los efectos de la COVID-19 en el patrón de uso (número de pacientes atendidos en urgencias, hospitalizaciones, ratio de hospitalización y clasificación por prioridades) de los Servicios de Urgencias (SU) de un hospital terciario de referencia. Métodos: Estudio retrospectivo, observacional y monocéntrico, realizado en los SU del Complejo Hospitalario Virgen de las Nieves (Granada, España). La información se recogió en los tres hospitales que pertenecen al Complejo Hospitalario Virgen de las Nieves (es decir, el Hospital General, GH; el Hospital Infantil, CH; y el Hospital Neurotraumatológico, NTH) desde el 1 de febrero hasta el 31 de julio de 2019 y 2020. Resultados: En el periodo analizado se produjeron 71236 atenciones en urgencias frente a 118382 en el mismo periodo de 2019, lo que supone una reducción global del 38,83%. Considerando las hospitalizaciones, hubo 6841 frente a 7648 (2020 y 2019, respectivamente) lo que da una reducción global del 10,55%. La distribución de las prioridades no mostró un patrón definido; mientras que los SU de CH y NTH mostraron cambios claros en su distribución, no se observaron cambios notables en el SU de GH. Conclusión: La pandemia de Covid-19 cambió drásticamente el patrón de derivación a urgencias en nuestro hospital terciario de referencia. Se constató una notable reducción de los pacientes atendidos en urgencias y las hospitalizaciones, junto con un pronunciado aumento de ratio de hospitalización que en algunos casos alcanzó casi el 50%. Esto podría explicarse por muchas razones, como el miedo al contagio y el bloqueo que presumiblemente provocó una disminución de los casos menos graves atendidos. Posiblemente, los efectos de COVID-19 pueden haber sido influenciados indirectamente por el sistema sanitario de cada país. La pandemia de COVID-19 constituye uno de los mayores retos de la medicina moderna, entender mejor estos cambios y el impacto que COVID-19 ha causado en el patrón de uso de los servicios de urgencias probablemente nos llevará a gestionar y utilizar mejor nuestros sistemas de salud pública en el futuro

Developing a practical guide for teaching histology: an evaluation of the didactic components

The Didactic Guide is a valuable tool complementing and making learning more dynamic. It is done using creative didactic strategies that simulate the presence of the tutor and generate a dialogue in order to offer students different possibilities to improve their understanding and self-discovery learning.This way the student is the protagonist of his own learning process. In this context, is highly important to consider the self discovery learning as a goal facilitating significant learning. The use of practical guides enables students to manage their own time, goals, techniques, contents and evaluation. In medical histology teaching several models of didactic guides could be use, and they normally include numerous activities, text, questionnaires, pictures, and drawings that may enhance the effectiveness of this tool in the learning process. In this work we have evaluated the usefulnes of different sections of a histology didactic guide in order to determine the key sections that enhance the learning process in human histology. For this purpose, a practical histology guide was designed with different sections: message text, theoretical text, objectives, drawings, pictures, clinical cases, games, blank spaces for self notes and drawing and final self evaluation questions. First, a simple questionnaire was applied in 90 students enrolled in histology practical seccions to analyze the student´s perceptions and preferences related to the histology guide. Finally, for all questionnaires average results and standard deviations were calculated for each option and all participants, as well for each gender, separately. Comparisons were done for drawings vs drawing blank spaces, teoric content vs notes blank space, drawings vs pictures and for each gender separately using Mann-Whitney non-parametrical test. Our findings revealed that visual strategies such as images and pictures were considered to be more useful for learning histology in the practical session. Similary, the students rated the self evaluation questions and blank spaces for self notes and drawing to be more attractive to the students. However, texts with theoretical information, messages, objectives, and clinical cases revealed to be less useful for the students in the learning process of medical histology. Moreover, statistically significant differences between theoretical content vs notes blank space was observed. All these results point out the importance of including pictures and drawings in the practical guide accompained of blank spaces that allow the development of creativity and autonomy that lead the students into a self discovery learning. Interestingly the students do not appreciate the presence of theoretical background in the practical guide as relevant information for their academic formation in the practical session

Immunohistological exacerbation control of vernal kerato-conjunctivitis with tacrolimus ointment

La queratoconjuntivitis vernal implica un gran número de complicaciones a nivel de la superficie ocular, pudiendo llegar a causar grandes alteraciones a ese nivel en pacientes de corta edad. En muchos casos es necesario aplicar tratamiento corticoideo tópico, a pesar de los efectos secundarios que puede acarrear al paciente. De ahí la importancia de encontrar tratamientos alternativos a éste como inmunosupresores tópicos donde el tacrólimus emerge como una nueva opción terapéutica. El objetivo de este estudio fue evaluar los efectos terapéuticos de la pomada de tacrólimus en pacientes con queratoconjuntivitis vernal. Para ello se realizó un estudio retrospectivo, seleccionando cuatro pacientes diagnosticados de queratoconjuntivitis vernal, todos ellos menores de 7 años, a los cuales se les aplicó la pomada de tacrólimus en el Servicio de Oftalmología del Hospital Universitario San Cecilio. Se determinó la gravedad de la patología en estos casos y la efectividad del tacrólimus, utilizando un sistema novel de calificación de exacerbación para enfermedad alérgica conjuntival 5-5-5. Los pacientes habían recibido tratamiento previamente con antihistamínicos y/o corticoides tópicos durante una mediana de 2 años, administrándose posteriormente pomada de tacrólimus. Tras tres meses de tratamiento con tacrólimus, se evidenció una mejoría clínica significativa evolucionando de un estado inicial de queratoconjuntivitis vernal moderada a leve sin observarse efectos secundarios asociados. Por todo ello el uso de tacrólimus al 0,03% es un tratamiento seguro y efectivo para los pacientes que padecen queratoconjuntivitis vernal refractaria al tratamiento convencional.Vernal keratoconjunctivitis involves a large number of ocular complications; it is capable to cause a diverse numbers of alterations in young patients. In many cases, it is necessary to apply corticosteroid therapy, although the side effects leaded to their use, therefore the importance of finding alternative treatments to it as topical immunosuppressants where tacrolimus emerges as a new therapeutic option. The aim of this study was to evaluate the therapeutic effects of tacrolimus in patients with vernal keratoconjunctivitis. For this retrospective study, we chose four patients diagnosed with vernal keratoconjunctivitis, under than 7 years, in whom topical tacrolimus was applied at the Department of Ophthalmology of the University Hospital San Cecilio. The severity of the disease in these cases and the effectiveness of tacrolimus were evaluated using a novel scoring system named 5-5-5. The patients received previous treatment with antihistamines and / or topical corticosteroids for a median of two years with no clinical outcome. After three months of treatment with tacrolimus, significant clinical outcome was achieved, evolving from an initial state of moderate vernal keratoconjunctivitis to a mild state with no side effects associated. Therefore the use of tacrolimus ointment is a safe and effective treatment for patients with vernal keratoconjunctivitis refractory to conventional treatment

Stem cell therapy in degeneration of the retinal pigment epithelium

Las enfermedades retinianas constituyen un grupo de patologías de gran impacto en la sociedad actual. Algunas entidades, como la degeneración macular asociada a la edad (DMAE), primera causa actual de ceguera en el mundo occidental, la enfermedad de Stargardt y la retinitis pigmentaria, comparten una alteración histológica común, la degeneración del epitelio pigmentario de la retina (EPR). Actualmente, no existe tratamiento para todas ellas, y las opciones terapéuticas de las que disponemos, no siempre son efectivas o no llegan a producir la completa recuperación, además de suponer una gran carga asistencial y un elevado coste. Ante esta situación surge la necesidad de investigar sobre la terapia con células madre para lograr la restauración o sustitución del EPR. Las células madre se presentan como una alternativa terapéutica para estos pacientes, que está mostrando resultados prometedores. En este trabajo se realiza, en primer lugar un resumen sobre las generalidades de estas patologías, para después hacer un recorrido por la trayectoria de la terapia celular en la patología retiniana en los últimos años. Se describen los hallazgos principales en cuanto a diferentes tipos celulares: células madre embrionarias, fetales, de cordón umbilical y hematopoyéticas y mesenquimales procedentes de médula ósea. Se comentan además algunas de las investigaciones y ensayos clínicos más significativos que se están llevando a cabo actualmente alrededor de todo el mundo.Retinal diseases are a group of diseases with great impact in today´s society. Some entities, such as age-related macular degeneration (AMD), first current cause of blindness in the western world, Stargardt´s disease and retinitis pigmentosa, share a common histological alteration, degeneration of the retinal pigment epithelium (RPE). Currently, there is not treatment for all of them, and treatment options that are available not always achieve healing or not produce the complete recovery, representing a large healthcare burden and high cost. This situation arises the need for research on stem cell therapy to achieve the restoration or replacement of the RPE. Stem cells are presented as a therapeutic alternative for these patients, that is showing promising results. In this work, firstly we do a summary about the general characteristics of these pathologies, and subsequently we do a journey through the path of cell therapy in retinal pathology in recent years. We describe the main findings about some different cell types: embryonic, foetal, from umbilical cord and bone marrow derived hematopoietic and mesenchymal stem cells. Also we discusse some of current investigations and major trials that are being conducted at present round the world

New teaching era for histology: from glass slides to virtual microscope as an alternative for selfdiscovery learning

Medical histology is a basic science that deals with concepts and facts regarding the microscopic structure of the human body. Histology has traditionally been taught as a lecture and microscopybased practical course using glass slides and microscopes and it is based on reception learning. However, a new era has been implemented using virtual microscope in order to improve the selfdiscovery learning process. Self-discovery learning is a constructive learning method that takes place without systematic external guidance and differs from tutorization and continuous instructions of reception learning method. The use of virtual microscope implies autonomous exploration of the histological images by simply dragging the mouse and changing the file of interest accompanied by the observation at different magnifications with a click. This method increases discussion and collaboration while increasing the speed and efficiency of learning without the need of light microscope. Virtual microscope encourages active learning environment and also places the students at the forefront of their own learning process being an useful tool for self- discovery learning. The knowledge about the students’ perceptions and their preferences is necessary for better design of self-discovery strategies in medical histology. In this study we have investigated male and female student´s preferences for optical (OM) and virtual microscope (VM) in a medical histology practical course. To achieve this, 90 first year medical students enrolled in medical histology course were evaluated. All students received 10 practical histology units (20 hours) where 5 (10 hours) units were taught using OM and 5 units (10 hours) with VM. Each student received both methods during the practical course. Each student completed a questionnaire after the whole practical units were performed in order to evaluate the student´s perceptions and preferences. The questionnaire consisted on four questions regarding OM and four questions related to VM the students have to answer to each question using a Likert scale from 1 to 5. Finally, a statistical test was use to analyze the results on the students perception´s and preferences for OM vs VM. Our results showed that both, OM and VM are adequate for histology learning as revealed by the high scores obtained for both types of methods. OM and VM tools were easy to manage and facilite the localization of histological structures during the visualization for all the students. However, most of the students significantly prefer to use VM to study the histological components of human tissues. The gender analysis revealed differences being statistically significant for men vs women for VM. These results suggest that VM should be included as an important tool for teaching human histology due to promote the self-discovery learning by the students

Bilateral neurotrophic corneal ulcers associated with trigeminal neuralgia

La patología corneal es una de las afecciones oculares a nivel de la población que más afectan a la calidad visual (Whitcher et al 2001)). Entre las patologías que mayor alteración producen en la anatomía y fisiología ocular encontramos aquellas que van a afectar al trofismo corneal. Para mantener dicho trofismo corneal, es necesario que las estructuras que integran la superficie ocular, como son el epitelio conjuntival y corneal, glándulas lagrimales accesorias, así como la unidad funcional que constituyen junto con la película lagrimal, párpados y arcos neurales reflejos (cuya vía aferente principal, está vehiculizada por la rama oftálmica del trigémino), tengan un funcionamiento correcto e integrado. La alteración de cualquiera de estos elementos puede conducir a la aparición de una lesión corneal. Así, existen patologías como las úlceras neurotróficas que se producen como resultado de una disminución de la sensibilidad corneal por una lesión del nervio trigémino, especialmente de sus ramas nasociliar y nervios ciliares largos, encargados de la inervación sensitiva corneal

Rapidly progressive conjunctival melanoma

Hombre de 73 años que presenta una lesión nodular pigmentada a nivel inferonasal de su conjuntiva bulbar. El estudio histopatológico mostró una proliferación neoplásica melanocítica caracterizada por una proliferación vascular en la base de la lesión con células invasivas de melanoma positivas para Melan-A. El paciente fue sometido a una escisión y una esclerotomia superficial. No se evidenciaron signos de recurrencia después de 12 meses de seguimiento. Sin embargo, es necesario realizer un seguimiento a más largo para mayor seguridad.A 73-year-old male presented with a pigmented nodular lesion in the inferonasal bulbar conjunctiva. Histopathological examination revealed a neoplastic melanocytic proliferation. This was characterized by vessel proliferation within the base of the lesion and invasive melanoma cells, positive for Melan-A. The patient underwent a dry “no touch” excision and a superficial sclerectomy. There were no signs of recurrence after 12 months of follow-up. However, it is necessary to perform a longer follow-up for greater security

Aislamiento de células epiteliales corneales a partir del limbo esclerocorneal humano

Introducción: La obtención de cultivos celulares epiteliales corneales humanos podría ser de gran utilidad tanto para la investigación básica como para su aplicación clínica en el tratamiento de diversas enfermedades corneales. Material y Métodos: Muestras de limbo esclerocorneal procedentes de donante humano cadáver se pusieron en cultivo con medios específicos para células epiteliales con distintos factores de crecimiento. En la mitad de los cultivos se utilizaron células alimentadoras 3T3. Resultados: Se obtuvieron cultivos primarios de células epiteliales corneales con un alto grado de proliferación, sin importar si el crecimiento se dio sobre células 3T3 o no. La tasa de contaminación de los cultivos fue menor en aquellos donde sí se encontraban estas células alimentadoras. Discusión: La obtención de células epiteliales corneales es posible en el laboratorio a partir de pequeñas biopsias del limbo esclerocorneal tras su expansión en cultivo, utilizando una técnica de cultivo estándar, fácilmente reproducible.Introduction: The achievement of human corneal epithelial cultures could be useful not only for research purposes, but also for clinical applications in the treatment of several corneal diseases. Material and Methods: Sclerocorneal limbi were obtained from human donors and cultured in specific medium containing several hormones and growth factors. Half of the cultures were established using a layer of 3T3 feeder cells. Results: we obtained primary cultures of corneal epithelial cells with a high proliferation rate in culture. No relationship with the use of a 3T3 feeder cell layer was found, but the likelihood of fibroblast contamination in the epithelial cultures was lower when these cells were used. Discussion: Establishing primary cultures of corneal epithelial cells from small explants of limbal tissue is a technique that can be carried out in the laboratory using standard culture methods.Financiado por: FIS 08/61