Santiago Nogué

Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial

BACKGROUND Risk factors for nosocomial pneumonia, such as gastro-oesophageal reflux and subsequent aspiration, can be reduced by semirecumbent body position in intensive-care patients. The objective of this study was to assess whether the incidence of nosocomial pneumonia can also be reduced by this measure. METHODS This trial was stopped after the planned interim analysis. 86 intubated and mechanically ventilated patients of one medical and one respiratory intensive-care unit at a tertiary-care university hospital were randomly assigned to semirecumbent (n=39) or supine (n=47) body position. The frequency of clinically suspected and microbiologically confirmed nosocomial pneumonia (clinical plus quantitative bacteriological criteria) was assessed in both groups. Body position was analysed together with known risk factors for nosocomial pneumonia. FINDINGS The frequency of clinically suspected nosocomial pneumonia was lower in the semirecumbent group than in the supine group (three of 39 [8%] vs 16 of 47 [34%]; 95% CI for difference 10.0-42.0, p=0.003). This was also true for microbiologically confirmed pneumonia (semirecumbent 2/39 [5%] vs supine 11/47 [23%]; 4.2-31.8, p=0.018). Supine body position (odds ratio 6.8 [1.7-26.7], p=0.006) and enteral nutrition (5.7 [1.5-22.8], p=0.013) were independent risk factors for nosocomial pneumonia and the frequency was highest for patients receiving enteral nutrition in the supine body position (14/28, 50%). Mechanical ventilation for 7 days or more (10.9 [3.0-40.4], p=0.001) and a Glasgow coma scale score of less than 9 were additional risk factors. INTERPRETATION The semirecumbent body position reduces frequency and risk of nosocomial pneumonia, especially in patients who receive enteral nutrition. The risk of nosocomial pneumonia is increased by long-duration mechanical ventilation and decreased consciousness.

Structural and Functional Imaging Studies in Chronic Cannabis Users: A Systematic Review of Adolescent and Adult Findings

Background The growing concern about cannabis use, the most commonly used illicit drug worldwide, has led to a significant increase in the number of human studies using neuroimaging techniques to determine the effect of cannabis on brain structure and function. We conducted a systematic review to assess the evidence of the impact of chronic cannabis use on brain structure and function in adults and adolescents. Methods Papers published until August 2012 were included from EMBASE, Medline, PubMed and LILACS databases following a comprehensive search strategy and pre-determined set of criteria for article selection. Only neuroimaging studies involving chronic cannabis users with a matched control group were considered. Results One hundred and forty-two studies were identified, of which 43 met the established criteria. Eight studies were in adolescent population. Neuroimaging studies provide evidence of morphological brain alterations in both population groups, particularly in the medial temporal and frontal cortices, as well as the cerebellum. These effects may be related to the amount of cannabis exposure. Functional neuroimaging studies suggest different patterns of resting global and brain activity during the performance of several cognitive tasks both in adolescents and adults, which may indicate compensatory effects in response to chronic cannabis exposure. Limitations However, the results pointed out methodological limitations of the work conducted to date and considerable heterogeneity in the findings. Conclusion Chronic cannabis use may alter brain structure and function in adult and adolescent population. Further studies should consider the use of convergent methodology, prospective large samples involving adolescent to adulthood subjects, and data-sharing initiatives.

Ecstasy: A common cause of severe acute hepatotoxicity

BACKGROUND/AIMS Ecstasy is a synthetic amphetamine recently identified as a possible cause of acute liver injury. This drug is consumed by young people and has a marked effect on improving sociability. The extent of ecstasy-associated severe hepatic damage is unknown to date. METHODS The clinical histories of 62 patients with acute liver failure admitted to the Intensive Care Liver Unit between January 1994 and December 1996 were reviewed to assess the frequency, the epidemiological, clinical and histological characteristics and the outcome of ecstasy-induced severe hepatitis. RESULTS Over this period of time, five patients (8%) were admitted because of ecstasy-induced acute liver failure, representing 31% of the cases with drug hepatotoxicity. Ecstasy was the second most common cause of liver injury in patients under the age of 25 years, being 20% in this subset of patients and 36% after ruling out the cases of viral etiology. All the patients had severe liver disease of acute onset, with jaundice, high peak of serum transaminases activity, hypoglycemia and low prothrombin activity, but no hepatic encephalopathy. Full recovery was observed in all cases from 3 to 12 months. CONCLUSIONS Ecstasy is responsible for a relatively high number of cases of acute liver failure in young people. Therefore, the use of this drug should be investigated in all patients with severe hepatitis of unclear origin. Efforts must be made to advise young people of the risks of ecstasy consumption.

Problemas relacionados con la medicación como causa del ingreso hospitalario

Fundamento Mediante este estudio se ha pretendido: a) identificar y caracterizar los problemasrelacionados con la medicacion (reacciones adversas, fracasos terapeuticos relacionados con ladosis e intoxicaciones) que provocan ingresos en el Hospital Clinic de Barcelona, a traves delservicio de urgencias; b) conocer que tipo de medicamentos se ve implicado con mas frecuencia;c) identificar los factores que predisponen al ingreso hospitalario por problemas relacionadoscon la medicacion, y d) evaluar cuantos de estos ingresos se podrian haber evitado. Pacientes y metodo El estudio ha sido de caracter prospectivo y se ha realizado durante los mesescomprendidos entre agosto y noviembre de 1999 y entre enero y mayo de 2000. Duranteestos periodos se han obtenido un total de 1.800 ingresos correspondientes a 1.663 pacientes. Resultados El numero de ingresos debidos a problemas relacionados con la medicacion, incluyendolos casos definitivos, probables y posibles, ha sido de 215 (11,9%). De estos casos, 108(50,2%) han correspondido a efectos adversos, 100 (46,5%) a fracasos terapeuticos relacionadoscon la dosis (fundamentalmente mal cumplimiento) y siete (3,3%) a intoxicaciones. Si seexcluyen los casos posibles para conseguir una relacion causal mejor definida, el numero deproblemas relacionados con la medicacion como causa de ingreso ha sido de 139 (7,7%).Siguiendo los criterios de Schumock y Thornton modificados, un 68,4% de los ingresos debidosa problemas relacionados con la medicacion se ha considerado evitable. La mayoria de losingresos evitables son debidos al mal cumplimiento, seguidos de ausencia de profilaxis y monitorizaciono seguimiento inapropiado. Conclusiones El numero de ingresos debidos a problemas relacionados con la medicacion eselevado y en muchos casos se podrian haber evitado.

Trends in illicit drug emergencies: The emerging role of gamma-hydroxybutyrate

Background: Previously used as a general anesthetic, γ-hydroxybutyrate is now used as a recreational drug. Not surprisingly, an increasing number of acute overdose cases requiring emergency medical care have been reported and described, especially in the United States. Objectives: To determine the number and percentage of γ-hydroxybutyrate overdoses over a 15-month period and to describe the clinical hallmarks and course of this new drug in overdose. Methods: All toxicological emergencies, including those caused by illicit drug consumption, were recorded for 15 months in an urban public hospital emergency department. Accurate toxicological history was obtained from the patients and, if γ-hydroxybutyrate was suspected, confirmation was performed by urine mass spectrometry. The study data were compared with data recorded in the same emergency department in 1989. Results: The total number of toxicological emergencies attended in our emergency department have remained unchanged during the last decade, with a significant decrease in number of opiate overdoses and an increase in the number of cocaine, amphetamine, and γ-hydroxybutyrate overdoses. During the study period, 104 γ-hydroxybutyrate overdoses presented to the emergency department (3.1% of all toxicological emergencies), ranking second in illicit drugs requiring emergency consultation. The profile of a patient with γ-hydroxybutyrate intoxication is well defined: a young individual (23±5 years), male (64%), emergency department presentation on weekends (90%), with simultaneous ethanol consumption (73%) and ingestion of additional illicit drugs (86%), decrease of consciousness being the main complaint in all cases [16% with Glasgow Coma Scale (GCS)=3]. Complete recovery without sequelae occurred in all cases. Conclusion: Health authorities must be aware of the hazards of recreational γ-hydroxybutyrate, and physicians must be cognizant of this recent cause of coma among youths presenting to the emergency departments.

Liquid ecstasy intoxication: clinical features of 505 consecutive emergency department patients

Background To describe the epidemiological profile and clinical manifestations of liquid ecstasy (GHB) poisonings. Methods All cases of GHB poisoning or overdose admitted to the Emergency Department (ED) of the Hospital Clinic (Barcelona) between 2000 and 2007 were recorded. Results A total of 505 patients (mean age 24.7 years, 68% men) were included. Most patients were brought to the hospital by ambulance (98%), during the weekend (89%) and during the early morning (75%). Symptoms began in a public place in 97%. Reduced consciousness was the most important clinical manifestation: 72% of patients had a Glasgow Coma Score of ≤12. 76% of patients had consumed other drugs: ethanol (64%), amphetamines and derivates (30%), cocaine (28%), ketamine (11%), cannabis (9%) and others (5%). Treatment was required in 26% of cases and an antidote was administered in 35 cases with no response. There were no deaths. The combined GHB group had a longer time to complete recovery of consciousness (71±40 vs 59±40 min, p<0.001) and a higher percentage of patients with severely reduced consciousness at ED arrival (54% vs 37%, p=0.01), need for treatment (29% vs 16%, p<0.01) and need for mechanical ventilation (3% vs 0%, p<0.05) compared with the pure GHB group. Conclusions GHB intoxication leading to reduced consciousness is a frequent reason for ED admission, above all in young people and in the early morning at the weekend. Symptoms are more severe in patients who have taken GHB in combination with other substances of abuse.

Urgencias por cocaína: un problema emergente

Fundamento y objetivo En los ultimos anos ha aumentado en Espana el consumo de cocaina, por lo que podrian estar produciendose cada vez mas episodios de sobredosis. El uso asociado de otras drogas de abuso puede potenciar su toxicidad y, por tanto, incrementar las consultas a los servicios de urgencias (SU). Pacientes y metodo Se han recogido los datos de los pacientes que consultaron al SU y que referian consumo de cocaina en las horas previas. Se ha analizado la relacion entre la droga y el motivo de consulta y se han revisado las historias clinicas de una muestra para conocer su perfil clinico. Resultados Durante un periodo de 3 anos (2002-2004) se identifico a 745 pacientes (edad media de 31 anos, un 68% varones). La distribucion anual fue de 223 casos en el ano 2002, 232 en 2003 y 290 en 2004. El 53% de los pacientes consultaron durante el fin de semana y el 53% acudio al SU entre las 0 y las 12 h. Otras drogas asociadas al consumo de cocaina fueron el alcohol etilico (38%), los opiaceos (14%), el cannabis (13%) y los derivados anfetaminicos (9%). La cocaina fue el toxico causante del cuadro clinico en el 70% de los casos. Los motives principales de consulta fueron ansiedad o agitacion (48%) y dolor toracico o palpitaciones (25%). El 11% requirio ingreso hospitalario (19 casos en la unidad de cuidados intensivos) y se registraron 3 casos mortales. Conclusiones El consumo de cocaina, asociado casi siempre a otras drogas de abuso, ha generado un incremento de las consultas a los SU. Si bien la mortalidad es baja, el consumo de cocaine comporta morbilidad y frecuente ingreso hospitalario.

Functional connectivity alterations in brain networks relevant to self-awareness in chronic cannabis users

BACKGROUND Recreational drugs are generally used to intentionally alter conscious experience. Long-lasting cannabis users frequently seek this effect as a means to relieve negative affect states. As with conventional anxiolytic drugs, however, changes in subjective feelings may be associated with memory impairment. We have tested whether the use of cannabis, as a psychoactive compound, is associated with alterations in spontaneous activity in brain networks relevant to self-awareness, and whether such potential changes are related to perceived anxiety and memory performance. METHODS Functional connectivity was assessed in the Default and Insula networks during resting state using fMRI in 28 heavy cannabis users and 29 control subjects. Imaging assessments were conducted during cannabis use in the unintoxicated state and repeated after one month of controlled abstinence. RESULTS Cannabis users showed increased functional connectivity in the core of the Default and Insula networks and selective enhancement of functional anticorrelation between both. Reduced functional connectivity was observed in areas overlapping with other brain networks. Observed alterations were associated with behavioral measurements in a direction suggesting anxiety score reduction and interference with memory performance. Alterations were also related to the amount of cannabis used and partially persisted after one month of abstinence. CONCLUSIONS Chronic cannabis use was associated with significant effects on the tuning and coupling of brain networks relevant to self-awareness, which in turn are integrated into brain systems supporting the storage of personal experience and motivated behavior. The results suggest potential mechanisms for recreational drugs to interfere with higher-order network interactions generating conscious experience.

Indicadores de calidad para la asistencia urgente de pacientes con intoxicaciones agudas (Calitox-2006)

Resumen Se presenta un mapa de 24 indicadores para medir la calidad de la asistencia dada a los pacientes con intoxicaciones agudas que son atendidos en los servicios de urgencias. Se incluyen indicadores estructurales (disponibilidad de protocolos, stock de antidotos, tecnicas analiticas, sondas de lavado gastrico), indicadores de proceso (adecuacion de las tecnicas de descontaminacion digestiva, indicaciones de depuracion renal y de depuracion extrarrenal, uso de antidotos, indicacion de analisis toxicologicos, practica de electrocardiograma, demora asistencial, consulta psiquiatrica, parte judicial), indicadores de resultado (mortalidad, cumplimentacion de un conjunto minimo de datos del intoxicado, formacion continuada del personal) e indicadores administrativos (publicaciones).

Intoxicación por éxtasis líquido: estudio de 22 casos

Fundamento Describir las caracteristicas de la intoxicacion aguda por extasis liquido (acido gamma-hidroxibutirico, [GHB]). Pacientes y metodo Se recogen los datos epidemiologicos y clinicos de los pacientes con intoxicacion aguda por GHB visitados en urgencias a lo largo de un ano. Resultados Se han detectado 22 casos. El perfil clinico es el de un varon joven, que es conducido a urgencias durante el fin de semana, en horario nocturno, aquejado de una profunda disminucion del nivel de conciencia en el contexto de un consumo de diversas sustancias de abuso. De forma caracteristica, este cuadro se recupera espontaneamente en un periodo muy corto de tiempo. Conclusiones La intoxicacion por GHB ha aumentado espectacularmente en nuestro entorno y debe considerarse en el diagnostico diferencial de pacientes jovenes que son llevados a urgencias en coma.