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Biomedical subjects

M A de la Cal

Publications and source records attributed to M A de la Cal.

At least 19 recordsLinked to original sources
PubMed2005

Handwashing in the intensive care unit: a big measure with modest effects.

Handwashing is widely accepted as the cornerstone of infection control in the intensive care unit. Nosocomial infections are frequently viewed as an indicator of poor compliance of handwashing. The aim of this review is to evaluate the effectiveness of handwashing on infection rates in the intensive care unit, and to analyse the failure of handwashing. A literature search identified nine studies that evaluated the impact of handwashing or hand hygiene on infection rates, and demonstrated a low level of evidence for the efforts to control infection with handwashing. Poor compliance cannot be blamed as the only reason for the failure of handwashing to control infection. Handwashing on its own does not abolish, but only reduces transmission, as it is dependent on the bacterial load on the hand of healthcare workers. Finally, recent studies, using surveillance cultures of throat and rectum, have shown that, under ideal circumstances, handwashing can only influence 40% of all intensive care unit infections. A randomised clinical trial with the intensive care as randomisation unit is required to support handwashing as the cornerstone of infection control.

Clinical Trials as Topic↗
PubMed2004

Effectiveness and safety of enteral vancomycin to control endemicity of methicillin-resistant Staphylococcus aureus in a medical/surgical intensive care unit.

A prospective trial was undertaken to assess the effectiveness and safety of enteral vancomycin in controlling methicillin-resistant Staphylococcus aureus (MRSA) in an endemic setting. Over the 49 month period patients aged >14 years were enrolled, following admission to a medical/surgical intensive care unit (ICU) and expected to require ventilation for three days or more. A total of 799 patients were included in the trial. Period one, 1 July 1996-30 April 1997, (N=140), was observational. During period two, 1 May 1997-30 September 1998, (N=258), surveillance samples were obtained. MRSA carriers were isolated and received enteral vancomycin. During period three, 1 October 1998-31 July 2000, (N=400), all ventilated patients were given selective digestive decontamination (SDD) with polymyxin E, tobramycin, amphotericin B and vancomycin and four days of intravenous cefotaxime. The primary endpoints were: (1) incidence of patients with diagnostic samples positive for MRSA acquired on the ICU; (2) incidence of patients with vancomycin-resistant enterococci (VRE) in surveillance or diagnostic samples; (3) incidence of patients with samples positive for S. aureus with intermediate sensitivity to glycopeptides (GISA). The incidence of patients with MRSA in diagnostic samples were 31%, 14%, and 2% in periods one, two and three, respectively (P<0.001). There was a VRE outbreak involving 13 patients during period three. VRE disappeared with no change in policy. GISA was not detected. These findings support the effectiveness and safety of enteral vancomycin in the control of MRSA.

Aged↗
PubMed2001

Fine-needle aspiration biopsy of liver masses: diagnostic value and reproducibility of cytological criteria.

There are many helpful cytological criteria for the diagnosis of liver fine-needle aspiration biopsies (FNABs), but none of them are pathognomonic of primary or metastatic tumors. We analyzed the diagnostic value and reproducibility of 28 cytological parameters in FNABs from 140 hepatic masses, including 29 benign lesions, 49 hepatocellular carcinomas (HCCs), and 62 metastatic tumors, encompassing 48 adenocarcinomas (ACAs). Five different observers evaluated each sample, and the interobserver and intraobserver agreement was studied. Multivariable analysis showed that the criteria more closely associated with malignancy were irregular nuclear contour, three-dimensional cell groups, and atypical naked nuclei. Capillaries separating tumor cells and granular cytoplasm were strongly associated with HCCs, while eccentrically placed nuclei and necrosis were most commonly seen in ACAs and in metastatic tumors. The intraobserver and interobserver agreement was excellent for the final cytological diagnosis, and there was fair to very good interobserver agreement for 22 of the 28 criteria studied. Architectural features were less reproducible than pure cytological criteria. Intraobserver variability was not influenced by the years of experience in the field. A precise and strict definition of terminology rendered a better reproducibility of the cytological criteria.

Biopsy, Needle↗
PubMed2000

Accidental removal of endotracheal and nasogastric tubes and intravascular catheters.

OBJECTIVES: To characterize the rates of accidental removal of endotracheal tubes, nasogastric tubes, central venous catheters, and arterial catheters. To assess the efficacy of corrective measures aimed at reducing the accidental removal of these devices. DESIGN: Prospective, observational, and interventional study. SETTING: Eighteen-bed medical-surgical intensive care unit of a 650-bed tertiary care hospital. PATIENTS: Patients admitted to the intensive care unit who had any of the following devices in place for more than 24 hrs: endotracheal tube, nasogastric tube, central venous catheter, arterial catheter. MEASUREMENTS AND INTERVENTIONS: Data were collected on the date of placement of tubes and catheters, position of vascular catheters, date of removal, and reason for removal. The study involved three consecutive 6-month periods. At the end of the first and the second periods, information about rates of accidental removal was provided to the physicians and nurses. In addition, the personnel were instructed to be more vigilant and specific measures aimed at reducing the accidental removal were introduced. MAIN RESULTS: In the first period, 289 endotracheal tubes were placed and 13.1% (24.7 per 1000 days) were removed accidentally. In the second and third periods, 17.1% (25.5 per 1000 days) and 11.4% (15.1 per 1000 days) were removed accidentally, respectively. In the first period, 368 nasogastric tubes were placed and 41% (73.9 per 1000 days) were removed accidentally. In both the second and the third period, a significant reduction in the rate of accidental removal was observed (32.4% or 41.2 per 1000 days and 25.8% or 29.8 per 1000 days, respectively). A significant decrease was observed in the rates of accidental removal of central venous catheters from 7.5% (12.4 per 1000 days) in the first period to 3.6% (5.4 per 1000 days) in the second period. The rate of arterial catheters accidentally removed expressed according to the time at risk significantly decreased from 46.5 per 1000 days in the first period to 19.1 per 1000 days in the second period and 25.3 per 1000 days in the third period. CONCLUSIONS: The information provided by the rates of accidental removal expressed by patient-days is helpful to compare results obtained in populations with different times of follow-up. Education of medical personnel and limiting upper-extremity access to within 20 cm from any catheter or tube resulted in a significant reduction of patient-related removal of tubes and catheters.

Catheterization, Central Venous↗
PubMed2000

Systemic hemodynamics, gastric intramucosal PCO2 changes, and outcome in critically ill burn patients.

OBJECTIVES: To define the hemodynamic and gastric intramucosal PCO2 (PiCO2) changes during the first 48 hrs after burn trauma and to analyze their relationship with outcome. DESIGN: Prospective, observational study in a cohort of consecutively admitted critically ill burn patients. SETTING: Intensive care burn unit in a university hospital. PATIENTS: Forty-two patients with burns covering >20% of body surface area or inhalation injury. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were monitored with an oximetric pulmonary arterial catheter and a gastric tonometer to measure PiCO2. The difference between arterial and gastric mucosal PCO2 (P[i-a]CO2) was considered indicative of gastric mucosal hypoxia. Hemodynamic and PiCO2 measurements were performed during the first 48 hrs after admission. Patients suffered burns covering 36.1% +/- 14.3% (mean +/- SD) and 45.3% +/- 21.9% of body surface area (survivors and nonsurvivors, respectively). All patients were successfully resuscitated by conventional standards. Nonsurvivors (n = 16) died a median of 17 days after admission. In univariate analysis, the presence of shock during the resuscitation phase, age, mixed venous pH, P[i-a]CO2, right atrial pressure, pulmonary arterial pressure, pulmonary arterial occlusion pressure, cardiac index, systemic and pulmonary vascular resistance, left ventricular stroke work index, mixed venous oxygen saturation, and systemic oxygen delivery, consumption, and extraction ratio, measured over the first 12 hrs after admission, were significantly (p < .05) different between survivors and nonsurvivors. These differences disappeared after 12 hrs after admission. Multivariate analysis identified age, percentage body surface area burned, and oxygen delivery index (6 hrs after admission) as factors independently associated with a poor outcome. P[i-a]CO2 (12 hrs after admission) was significantly greater in patients with than in those without inhalation injury (17 +/- 13 torr [2.26 +/- 1.73 kPa] vs. 6 +/- 10 torr [0.79 +/- 1.33 kPa]; p = .005). Patients with a P[i-a]CO2 difference (6 hrs after admission) > or =10 torr (1.33 kPa) had a mortality rate of 56% vs. 25% of those patients with <10 torr (p = .044). CONCLUSIONS: Our data indicate that there are hemodynamic and biochemical changes that occur early after burn trauma that are associated with prognosis after an apparently successful resuscitation. Particularly, a hemodynamic profile characterized by systemic acidosis, low systemic blood flow, and systemic and pulmonary vasoconstriction early after trauma is associated with a poor outcome. Additionally, intestinal mucosal acidosis occurs after burn trauma, is influenced by inhalation injury, and is a variable related to outcome.

Adolescent↗
PubMed1999

Reliability of the routine cytological diagnosis in bladder cancer.

OBJECTIVES: To establish the reliability of three cytopathologists for cytological diagnosis of primary bladder tumors. METHODS: Preoperative voided urine specimens of 71 patients with bladder cancer and 55 noncancer controls were retrospectively and blindly reviewed by 3 independent cytologists, and their results compared. The estimation of the interobserver agreement was calculated using the weighted kappa coefficient. A multivariate analysis was carried out to identify the factors associated with the disagreement between the three observers. The sensitivity and specificity for each of the participants was calculated in order to clearly identify the origin of the disagreement, in terms of the performance of the diagnostic test in the hands of each observer. A comparison of the overall diagnostic performance was made by plotting sensitivity versus 1-specificity. RESULTS: The weighted kappa coefficient among the 3 observers was 0.46. The multivariate analysis did not identify any variable that could have caused such disagreement. Vast differences in sensitivity and specificity were detected between observer 1 (sens. 0.90, spec. 0.45) and observers 2 (sens. 0.67, spec. 0.72) and 3 (sens. 0.71, spec. 0.80), but the overall diagnostic performance (sensitivity vs. 1-specificity) was superimposable in the 3 cases (p = NS). CONCLUSIONS: Simple, reproducible and agreed-on-diagnostic criteria should be established to yield reliable results in a group of cytologists. The consideration of individual diagnostic performances can give a false idea of homogeneity between observers. In this field, concordance analysis makes quality control reliable and should be a routine procedure of any pathology department.

Carcinoma, Transitional Cell↗
PubMed1999

[Reliability of routine cytological diagnosis in bladder cancer].

OBJECTIVES: To establish the reliability of three cystopathologists for cytological diagnosis of primary bladder tumors. METHODS: Pre-operative voided urine specimens of 71 patients with bladder cancer and 55 healthy controls were retrospectively and blindly reviewed by 3 independent cytologists, and their results--positive for bladder cancer, negative or inconclusive--were compared with each other. The estimation of the interobserver agreement was calculated using the weighted kappa-coefficient (k). A multivariative analysis was carried out to identify the factors associated with the disagreement among the three observers. The sensitivity and specificity for each of the participants were calculated in order to clearly identify the origin of the disagreement, in terms of the performance of the diagnostic test in the hands of each observer. A comparison of the overall diagnostic performance was made by plotting sensitivity versus 1-specificity. RESULTS: The weighted k coefficient among observers was 0.46. The multivariative analysis did not identify any variable that could have caused such disagreement. Large differences in sensitivity and specificity were detected between observer number 1 (sens., 0.90, spec., 0.45) and observers number 2 (sens., 0.67, spec., 0.72) and number 3 (sens., 0.71, spec., 0.80), but the overall diagnostic performance (sensitivity vs 1-specificity) was superimposable in the three cases (p = ns). CONCLUSIONS: Simple, reproducible and agreed-on diagnostic criteria should be established to yield reliable results in a group of cytologists. The consideration of individual diagnostic performances can give a false idea of homogeneity between observers. In this field, concordance analysis makes quality control reliable and should be a routine procedure of any pathology department.

Female↗
PubMed1999

[Changes in prostatic histological composition in subjects with prostatitis].

OBJECTIVES: To explore the links between the histological composition of the prostate and the symptoms related to the clinical BPH. MATERIAL & METHODS: The prostates of 34 patients with symptoms of BPH and 17 asymptomatic patients were biopsied. Using light microscopy, the ratio of stromal to glandular surfaces was calculated. The main dimensions of 5 epithelial cells randomly selected, were examined under electron microscopy in each case. The number and length of microvilli, and the number of secretory granules were determined. The results of symptomatic and asymptomatic subjects were compared by means of Student's t and Mann-Whitney's U tests. RESULTS: The mean ratio of stromal and glandular surfaces came to 4:1 and 6.5:1 in the symptomatic and asymptomatic patients, respectively. The difference was not statistically significant (p = 0.18). Although the average cellular surface of the symptomatic patients was inferior to that of the asymptomatic subjects (74 and 88 mu2. respectively), the differences did not reach statistical significance (p = 0.14). Similarly, the mean nuclear surface of the symptomatic and asymptomatic patients (19.5 and 20.8 mu2, respectively) did not differ (p = 0.48). No differences were detected in the number of secretory granules and microvilli, nor in the length of the microvilli. CONCLUSIONS: The occurrence of symptoms related to the clinical BPH is not due to differences in the composition of the prostate. No clear links seem to exist between the structural changes in the epithelial cells and the development of symptoms. Considering the proportions of epithelium and stroma, therapy focused in the prostatic stroma should yield the best results.

Aged↗
PubMed1998

Delayed graft function does not reduce the survival of renal transplant allografts.

BACKGROUND: The aim of the present study was to investigate the effect of delayed graft function (DGF) in graft outcome when adjusted by the presence of acute rejection in the first month after transplantation. METHODS: A total of 437 cadaveric renal transplant patients on cyclosporine and steroids were included in the study. Variables related to donor, recipient, and graft were prospectively collected. RESULTS: The incidence of DGF was 44.4%. When patients dying with a functioning graft were censored, graft survival rates at 1 and 6 years were similar in patients with immediate function to those with DGF, when rejection was not present (96% and 81% vs. 95% and 83%, respectively). Rejection negatively influenced graft survival rates at 1 and 6 years, both in patients with immediate graft function (80% and 73%, P<0.05 vs. no DGF/no rejection) and more deeply in those with associated DGF (77% and 62%, P<0.001 vs. no DGF/no rejection). Rejection was more frequently diagnosed in patients with DGF than in those with immediate graft function (50% vs. 39.9%, P<0.05). Length of hospitalization was longer and the number of needle core biopsies was higher in patients with DGF or rejection. The presence of both complications had an additive effect. CONCLUSIONS: This study showed that DGF did not adversely affect kidney graft survival in patients without rejection. However, it increased the length of hospitalization and the number of graft biopsies, thus increasing the cost of transplantation. Moreover, rejection was more frequent in patients with DGF, and it had a negative impact on graft outcome. Because the association of DGF and rejection gave the poorest outcome, an effort should be made to prevent both complications.

Adolescent↗
PubMed1997

The impact of malnutrition in morbidity and mortality in stable haemodialysis patients. Spanish Cooperative Study of Nutrition in Hemodialysis.

BACKGROUND: When assessed by single biochemical measurements, malnutrition in dialysis patients is associated with increased mortality, but there are few data evaluating abnormalities in anthropometry or composite nutritional scores and outcome. The aim of our study was to ascertain the prevalence and severity of malnutrition in 761 stable patients from 20 haemodialysis centres and its influence in morbidity and mortality after one year of follow-up. METHODS: Malnutrition was estimated by scoring four anthropometric indexes; body mass index (BMI), triceps skinfold thickness (TSF), mid-arm circumference (MAC), and mid-arm muscle circumference (MAMC); three biochemical measurements; serum albumin, serum transferrin and total lymphocyte count; and clinical examination. Mortality and hospitalizations were collected prospectively during the year of follow-up. RESULTS: A moderate/severe degree of malnutrition was presented by 51.6% of male and 46.3% of female patients. TSF was moderate-severely decreased in 41% without differences between males and females. MAMC was moderately decreased in 19.8% of males and in 8.1% of females (P < 0.001). Multiple logistic regression analysis showed that the predictors of malnutrition were: age > 65 years (OR = 1.96, CI: 1.22-3.14), male sex (OR = 1.95, CI: 1.24-3.07), comorbidity index (OR = 1.23, CI: 1.03-1.45), time on dialysis (OR = 1.13, CI: 1.08-1.18), duration of dialysis (OR = 0.73, CI: 0.63-0.85) and PCR related to ideal body weight (OR = 0.17, CI: 0.06-0.50). After 1 year of follow-up, data from 442 patients were available. A total of 68 patients died (15.4%) with cardiovascular diseases being the most frequent cause of death (57.3% of the cases). The predictors of mortality were: age (OR = 1.06, CI: 1.03-1.09), cardiovascular disease (OR = 2.13, CI: 1.19-3.83), neurological disease (OR = 2.96, CI: 1.41-6.15), nephroangiosclerosis (OR = 2.34, CI: 1.10-4.98) and total lymphocyte count (OR = 0.93, CI: 0.87-0.98). Hospitalization was needed in 44% of patients. The comorbidity index, serum albumin and age were the predictive factors of hospitalization. CONCLUSIONS: Protein-calorie malnutrition is frequent in haemodialysis patients. Fat depletion predominated in both sexes. Duration of dialysis and protein catabolic rate related to ideal body weight was the only predictor which could be influenced by a nutritional intervention. Morbidity appeared to be influenced by the comorbidity index and age was the strongest predictor of mortality. The only nutritional measurements predictive of morbidity and mortality were serum albumin and total lymphocyte count respectively. Therefore, the influence of malnutrition in morbidity and mortality can not be definitively stated.

Adolescent↗