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To explore the possibility of identifying skull fracture, with or without clinical signs, as a predictor of positive CT scans in mild traumatic brain injury (mTBI).Prospective cohort study, matched 1:1 for five potential confounding variables (age, sex, symptoms, mechanism of injury and extracranial trauma severity).The study was performed on patients with mTBI (Glasgow Coma Scale 15-14), with or without radiologically demonstrated skull fracture. The cohort with skull fracture included 155 patients selected from a sample of 5097 mTBI patients treated during 1998 at the Critical Care and Emergency Department of the Trauma Centre. The cohort without skull fracture was prospectively recruited from patients with mTBI treated in the same department from 2002-2005.The percentage of patients with intracranial lesion (IL) was significantly higher in mTBI patients with skull fracture than in those without. The risk of requiring neurosurgery was 5-fold higher when skull fracture was present. Of mTBI patients with skull fracture and IL, 63.2% showed no clinical signs of bone injury.Skull fracture, with or without clinical signs, in mTBI patients is associated with an increased risk of neurosurgically-relevant intracranial lesion.

Objectives: To determine the attributable mortality and excess length of stay (LOS) associated with the use of inadequate empirical antimicrobial therapy in patients with sepsis at admission to the intensive care unit (ICU). Methods: A retrospective matched cohort study was performed using a prospectively collected database at a 40 bed general ICU at a university public hospital. Patients who received inadequate antimicrobial therapy at admission to the ICU (exposed) were matched with controls (unexposed) on the basis of origin of sepsis, inflammatory response at admission, surgical or medical status, hospital- or community-acquired sepsis, APACHE II score (+ +2 points) and age (+ +10 years). Clinical outcome was assessed by in-hospital mortality, and this analysis was also performed in those pairs without nosocomial infection in the ICU. Results: Eighty-seven pairs were successfully matched. Fifty-nine exposed patients died [67.8% mortality (95% CI, 58.0‐77.6%)] and 25 unexposed controls died [28.7% mortality (95% CI, 19.2‐ 38.2%)] (P < 0.001). Excess in-hospital mortality was estimated to be 39.1%. The rate of nosocomial infection was significantly higher in patients with inadequate empirical therapy (16.1%) than in those treated empirically with adequate antibiotics (3.4%) (P 5 0.013). Excess in-hospital mortality was 31.4% after excluding those 17 pairs that developed a nosocomial infection in the ICU. Inadequate antimicrobial therapy was associated with a significant increment in duration of hospitalization (15 days in surviving pairs). Conclusions: Inadequate antimicrobial therapy at admission to the ICU with sepsis is associated with excess mortality and increases LOS.

Objective To analyse the repair of lesions of articular cartilage with periosteum-free implants and follow-up at 6 months. Design Thirty-six New Zealand rabbits, 4–6 weeks old, were used. Full-thickness articular cartilage defects in the medial femoral condyle were created. Spontaneous evolution occurred in 18 animals; the other 18 animals were treated with a free autogenous periosteal tibial implant fixed with Tissucol ® . Animals were killed in groups of six at 8, 12 and 24 weeks. Macroscopic, histologic and histochemical results were evaluated and analysed statistically using the Mann-Whitney U-test. Results The spontaneous evolution of the lesion did not lead to complete repair in any case. The periosteum-free implant provided complete repair of the lesion and statistically significant restoration of the articular surface. Conclusions In the rabbit, this study confirms the incomplete spontaneous repair of articular cartilage and the chondrogenic potential of tibial periosteum-free implants, with long-term maintenance of the macroscopic, histologic and histochemical characteristics of neo-cartilage. This raises the possibility of its use as an alternative method in the repair of circumscribed osteochondral lesions in young patients.

Echinocandins are the treatment of choice for patients with severe forms of candidaemia, including neutropenic patients and those episodes presenting with shock. There is little distinction between the three available echinocandins (caspofungin, anidulafungin and micafungin), but there is more clinical experience with caspofungin. Identifying patients who will benefit from early antifungal therapy using clinical tools such as the 'Candida Score' is an interesting strategy that may reduce the high mortality in critically ill patients with invasive fungal infections.

Objetivo. Investigar nuestras practicas clinicas, a fin de identificar oportunidades de mejora en el manejo medicoquirurgico de las hemorragias subaracnoideas (HSA) espontaneas. Pacientes y metodos. Estudio de cohortes, longitudinal, prospectivo, de las HSA atendidas consecutivamente en los servicios de cuidados criticos y urgencias de 29 hospitales publicos de Andalucia durante 20 meses, de 2000 a 2002. Se consideraron HSA los accidentes cerebrovasculares hemorragicos agudos con este diagnostico tomografico. Se analizaron los resultados a 12 meses y el manejo asistencial (terapeutica medica y quirurgica, tecnicas diagnosticas, tiempos asistenciales y complicaciones neurologicas especificas), comparandolo con las practicas clinicas que la evidencia cientifica ha demostrado de mayor utilidad. Se catalogaron como muertes potencialmente evitables los obitos por resangrado en pacientes sin estudio arteriografico o sin exclusion del aneurisma. Resultados. Se incluyeron 506 HSA. Se perdio durante el seguimiento el 5% de la muestra. Fallecieron 155 enfermos. Las variables no modificables de riesgo independiente para la mortalidad fueron: edad, genero masculino, antecedente de hipertension arterial, coma a la recepcion hospitalaria e hidrocefalia. Las variables influenciables de riesgo independiente para fallecer resultaron ser: ausencia de analgesia urgente, carencia de diagnostico arteriografico, aparicion de deterioro neurologico isquemico y resangrado. El 20% de la mortalidad global podria considerarse potencialmente evitable. Conclusiones. Aunque la letalidad es mayoritariamente dependiente de variables medicamente no influenciables (sexo, edad, antecedentes, gravedad clinica e hidrocefalia), los decesos, en un 20%, estan asociados a factores modificables.

The relationship between the distance to the Elche County Hospital, grouping the towns in its area of influence into four categories (over 29 km, 20 to 19 Km, under 20 Km and Elche proper), and the rates regarding the use of this hospital's emergency room services are studied based on a sample of 3,546 emergency cases treated in said hospital in 1985. The relative standardized risks by age (RelR) are significantly greater than 1 in all categories regarding that of 29 Km, concerning both men (1.36, 2.64, 3.86) and women (1.52, 2.02, 3.87). This is an association which follows a statistically significant upward trend concerning men (X ext-Mantel = 21.63 p less than 0.01) and women (X ext-Mantel = -18.85 p less than 0.01) as the distance decreases. We point out the limitations of the study, and some implications of the inverse association found (b = -0.38 for men and -0.29 for women p less than 0.05) are discussed with regard to refocusing health care services.

Introduccion. Los cambios que fisiologicamente tienen lugar en la circulacion cerebral durante la gestacion y el puerperio se conocen todavia poco. El Doppler transcraneal (DTC), por su inocuidad, es un metodo de estudio adecuado. Objetivo. Conocer la velocimetria DTC al final de la gestacion y en el puerperio precoz de gestantes sanas. Sujetos y metodos. Mediante DTC se estudiaron bilateralmente las arterias cerebrales anterior (ACA), media (ACM) y posterior (ACP). Ademas, se midieron la presion arterial y el hematocrito. En el analisis estadistico se utilizaron las variables velocidad media (VM), indice de pulsatilidad (IP), presion arterial media y hematocrito. Se compararon los resultados de 44 gestantes normotensas al final de la gestacion (semana 33 a termino) con los de un grupo control de 58 mujeres de similar edad, no gestantes y normotensas. A las gestantes se les repitio el estudio en el puerperio precoz (cinco primeros dias posparto), y se compararon los resultados en ambos tiempos. Resultados. La edad y la PAM fueron similares en los grupos gestante y no gestante. El hematocrito fue significativamente mas bajo en las primeras (p < 0,001). Las VM fueron significativamente mas bajas en las gestantes en todas las arterias (p < 0,001), mientras que los IP tambien fueron significativamente mas bajos en cuatro de los seis territorios estudiados (p < 0,005). En el puerperio se observo un aumento significativo de las VM en todas las arterias (p < 0,001) y de los IP en tres de ellas (p < 0,05). En esta fase aumento la presion arterial media (p < 0,05), mientras disminuyo el hematocrito (p < 0,001). Conclusiones. Las VM e IP bajos que se observan al final de la gestacion son compatibles con una vasodilatacion cerebral. En el puerperio precoz se incrementan las VM, probablemente en relacion con una relativa hiperperfusion.

Introduccion. La ecografia Doppler transcraneal (EDTC) tiene un uso creciente en el estudio de la hemodinamica cerebral en la preeclampsia/eclampsia. Al puerperio de estas pacientes se le ha prestado menos atencion. Objetivos. Mediante velocimetria por EDTC, por una parte comparar al final de la gestacion a pacientes preeclampticas (PE) con normotensas (NT), y, por otro lado, comparar los resultados de las PE en dos tiempos consecutivos: al final de la gestacion y en el puerperio precoz (PP). Pacientes y metodos. Realizamos EDTC con valoracion, bilateralmente, de las arterias cerebrales anterior (ACA), media (ACM) y posterior (ACP). Como parametros Doppler utilizamos la velocidad media (VM) y el indice de pulsatilidad (IP). Medimos la presion arterial (PA) y el hematocrito. En el analisis estadistico utilizamos como variables la VM, el IP, la PA media (PAM) y el hematocrito. Al final de la gestacion (33 semanas a termino) comparamos los valores medios de estas variables en las PE (n = 38) frente a las NT (n = 44). Por otra parte, comparamos los resultados obtenidos por las PE (n = 30) en dos tiempos consecutivos: al final de la gestacion y en el PP (primeros cinco dias posparto). Resultados. Al final de la gestacion, las VM fueron significativamente mas altas en las PE que en las NT en todas las arterias estudiadas. La PAM fue mas alta en el primer grupo, pero no hubo una correlacion significativa entre la PAM y la VM. Los IP fueron mas bajos en el primer grupo, con significacion estadistica en cuatro de las seis arterias. Las VM subieron significativamente en el PP en las PE, a pesar de existir un descenso de la PAM. Por el contrario, los IP no se modificaron. Conclusiones. Se hallo un patron de VM altas e IP bajos en las PE al final de la gestacion, lo que puede corresponder a un fracaso primario de la autorregulacion cerebral. En el PP se incrementaron las anomalias en la EDTC, a pesar del descenso de la PAM, hecho que podria justificar el predominio de los sintomas neurologicos que se describen en las formas tardias del sindrome

Objetivos. Conocer los valores normales de Doppler transcraneal (DTC) en puerperas normotensas (PNT) en nuestro medio. Evaluar la influencia de diferentes variables sobre el flujo sanguineo cerebral. Pacientes y metodos. Se realizaron 100 estudios DTC en PNT, y se sonorizaron seis arterias intracraneales. Se recogieron diversas variables como presion arterial, hematocrito y datos clinicos referidos al embarazo y parto. Se realizo un analisis descriptivo en el caso de las variables cualitativas, y las variables cuantitativas se expresaron como media mas desviacion estandar (DE). Se compararon las velocidades medias (VM) de cada arteria segun la lateralidad hemisferica, y su relacion con las cifras tensionales, el hematocrito y el resto de las variables. Resultados. Las VM expresadas como media y DE fueron: ACM derecha 73,10±14,33; ACM izquierda 75,68±15,84; ACA derecha 57,61±12,92; ACA izquierda 60,14±14,35; ACP derecha 42,77± 9,28; ACP izquierda 45,54±9,58. Se comprobo un aumento de VM en las arterias de lateralidad izquierda con respecto a las de lateralidad derecha, estadisticamente significativo. Ninguna de las variables del estudio influyo en los valores de flujo sanguineo cerebral. Conclusion. Los valores de VM fueron mas altos en el hemisferio izquierdo. Resulta util conocer valores de referencia puerperales en mujeres asintomaticas para poder identificar alteraciones hemodinamicas cerebrales propias de estados patologicos, como eclampsia tardia y angiopatia cerebral posparto

To describe the evolution of mortality due to ischaemic heart diseases in Andalucia between 1975 and 1992 and predict rates up to the year 2000.Descriptive study.The Autonomous Community of Andalucia. Patients and other participants. Deaths because of ischaemic heart diseases between 1975 and 1992 were obtained.The direct method was used for the standardisation of mortality rates for age and sex, with the European population as the standard. Logarithmic transformations of the standardised rates for mortality due to ischaemic heart diseases for both sexes were performed and the regression lines were adjusted. Between 1975 and 1992 the theoretical rates went down both in men and women. If the same tendency were maintained, we would expect to see a moderate reduction between 1992 and 2000 in men and in women.The tendency of mortality due to ischaemic heart diseases in Andalucia is downwards in both men and women.

Anemia is a frequent condition in burn patients due to a mixture of blood loss and chronic inflammation. Transfusions increase the probability of serious infections and reduce overall survival, especially when unrelated to perioperative blood loss. Once the surgical phase in burn patients is completed, the role of parenteral iron administration in the reduction of subsequent transfusions is not well established. Burn patients subjected to at least two surgeries and presenting progressive anemia after concluding the surgical phase, without major symptoms, were selected (n=12). Those patients with confirmed iron deficiency were treated with intravenous (i.v.) ferric carboxymaltose (n=8). Subsequently, these patients were compared with a group of 18 control patients selected from our historical database (n=1375), matching controls by age (±5 years), sex, and TBSA burn (±6%). The objective was to verify if i.v. iron administration reduced the need for blood transfusions after the surgical phase. The analysis concluded that none of the cases treated required transfusions compared to 44% of the controls. There were no side effects related to the i.v. iron infusion. This result suggests that i.v. iron supplementation with ferric carboxymaltose could be an alternative in anemic patients without major symptoms once the surgical phase is completed. Iron deficiency should be assessed and i.v. supplementation must be administered if required in burn patients showing progressive anemia.L’anémie, à la fois par pertes sanguines et inflammation, est fréquente chez les brûlés. Les transfusions, en particulier lorsque l’anémie n’est pas liée à la chirurgie, sont corrélées à la survenue d’infections sévères et à la mortalité. Une fois la phase chirurgicale terminée, le rôle de la thérapie martiale intraveineuse sur l’épargne transfusionnelle est mal connu. Nous avons évalué 12 patients brûlés, ayant été opérés au moins 2 fois et ne devant plus l’être, qui développaient une anémie progressive bien tolérée. Les 8 patients ayant une carence martiale ont reçu du carboxymaltose ferrique intraveineux. Ils ont été comparés avec 18 patients témoins, sélectionnés dans notre base de données de 1 375 dossiers, appariés sur l’âge +/- 5 ans, le sexe et la surface brûlée +/- 6%, l’objectif étant de vérifier si le traitement permettait effectivement de réduire les transfusions. Effectivement, aucun des patients traités n’a été transfusé, contre 44% des témoins. Aucun effet secondaire n’a été observé après administration de fer. Ceci suggère que des patients brûlés, chirurgie terminée, anémiques pauci- symptomatiques par carence martiale devraient recevoir un traitement martial IV.