Hospital Universitario Puerto Real

Puerto Real, Spain

Hospital Universitario Puerto Real

Puerto Real, Spain
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Neira Reina F.,Hospital Universitario Puerto Real | Ortega Garcia J.L.,Hospital Universitario Puerto Real
Revista de la Sociedad Espanola del Dolor | Year: 2016

Ketamine is a noncompetitive NMDA receptor antagonist and has a large action's mechanism, that involves receptors: AMPA, kainate, gamma-aminobutyric acid, opioids, monoamine, muscarinic and nicotinic. It is acting on voltage-dependent calcium channels, join in the synthesis and release of nitric oxide and inhibits serotonin reuptake. The interaction with these mechanisms of action makes it an important role on mechanisms of pain, inflammation, neuroprotection and opioid tolerance. In this paper we review the different routes of administration of ketamine, dosage, modes of administration, duration of treatment, indications according to levels of evidence available and side effects to set up its efficacy in the therapy of chronic pain and promote a more specific treatment, in those pathologies where it has shown greater efficacy. We perform a search in: Trip Database Population Intervention Comparison Outcome (PICO), National Guidelines Clearinghouse, Cochrane Library, Medline, CMA infobase, Health Services/ Technology Assessment, New Zealand Guidelines Group and Scottish Intercollegiate Guidelines Network. Ketamine is very versatile in their routes of administration: intravenous, intramuscular, subcutaneous, sublingual, oral, rectal, nasal, transdermic, epidural and subarachnoid; as well as their ways of administration (bolus, continuous infusion). However, the oral route is the most widely used and preferred for the treatment of chronic pain. However, we do not have an oral formulation marketed, making it difficult to use. Clinical use of ketamine requires careful patient's selection and assessment of the risk/benefit ratio. Ketamine has a potential risk of drug abuse; therefore, it should checked prior history of drug abuse. It is available evidence on the efficacy of ketamine in patients with refractory cancer pain and complex regional pain syndrome (CRPS). The use of low-dose intravenous ketamine has moderate evidence in CRPS, that does not justify its routine use in this syndrome. In neuropathic pain, ketamine has been particularly effective in controlling allodynia, hyperalgesia and hyperpathia, although there is controversy over its use. Oral ketamine may have a place in the treatment of chronic pain patients refractory to standard treatments. It is shown useful as an adjuvant to other analgesics, especially in patients treated with opioids, allowing reduction of doses and increasing pain relief in patients with chronic pain.

Quiros-Ganga P.L.,Hospital Universitario Puerto Real | Remon-Rodriguez C.,Hospital Universitario Puerto Real
Nefrologia | Year: 2012

Introduction: Survival rates between haemodialysis (HD) and peritoneal dialysis (PD) are the same but the associated comorbidity factors have a great impact on mortality. In the most recent studies the prognosis for PD has improved more than that for HD, although this has not meant an increase in the use of this treatment. Objectives: To determine whether the PD has improved over time with respect to its outcomes in our community, and determine the influence of comorbidity and treatment characteristics on the final results. Methods: Incident patients undergoing DP in Andalusia between 1999 and 2010. The cohort was divided into two groups: before and after 2004. Statistics: mean ± standard deviation, frequency, chi-square test, Student's t-test, risk determination (95% confidence interval), Kaplan-Meyer, log-rank and multivariate Cox proportional hazards models. Results: 1464 incident patients undergoing DP, 537 before 2004 and 927 after 2004. The baseline characteristics of both groups (age, diabetes) were similar, although the first group had more severe cardiovascular disease and higher Charlson comorbidity index. In the second period, more automatic PD and solutions of bicarbonate and icodextrin were used. The overall survival rate for patients was 55 months median and 65 mean. Within all subgroups (age, diabetes, cardiovascular disease, technique type) there was a greater tendency towards survival in the second period (the technique type, age and diabetes were found to be statistically significant variables). Age, cardiovascular disease, diabetes mellitus and incident cases before 2004 were all independent risk factors. This latter variable lost significance as bicarbonate or icodextrin-based solutions were introduced, which were independent risk factors. Technique survival showed a median of 68 months and a mean of 73 months. Dialysis solutions and the period when the DP was initiated were independent risk factors for the technique. Conclusions: DP has shown improved results in recent years; probably the new solutions are having a positive influence. As such PD should be implemented applying the criteria of effectiveness, free choice, efficiency and PD units should be fully developed within Nephrology Departments. © 2012 Revista Nefrología.

Fernandez Prieto R.M.,Hospital Universitario Puerto Real
Revista española de anestesiología y reanimación | Year: 2011

The antagonism of steroidal nondepolarizing neuromuscular blockers (NDMBs) moved forward recently with the introduction of sugammadex, the only drug able to immediately reverse the effects of curarization produced by NDMBs. This advance has necessitated reflection on the future role of pseudocholinesterase. In spite of the side effects of succinylcholine and published opinions on its use, this NDMB continues to be used in clinical anesthesia. Pseudocholinesterase is mainly found in the liver, plasma, and nervous system. The enzyme is synthesized in the liver in greater amounts than required although certain conditions lead to deficiency, which is usually asymptomatic. The only clinical expression is the apnea which develops after administration of succinycholine because this NDMB cannot be metabolized. In some patients, slight reductions in the antagonism of succinylcholine lead to rising neuromuscular concentrations of the drug in accordance with the degree and duration of the blockade. We review the various forms of pseudocholinesterase deficiency, including a discussion of genetic variants, clinical manifestations, and management. In addition to discussing the diagnosis of this condition and the clinical implications, we highlight the importance of practice protocols and access to a referral laboratory if one is not available within the immediate hospital.

Romero S.P.,Hospital Universitario Puerto Real | Garcia-Egido A.,Hospital Universitario Puerto Real | Escobar M.A.,Hospital Universitario Puerto Real | Andrey J.L.,Hospital Universitario Puerto Real | And 4 more authors.
International Journal of Cardiology | Year: 2013

Objectives: To assess the incidence of type 2 diabetes mellitus (DM) in patients with heart failure (HF), and to evaluate the effect of new-onset DM and glycemic control on the prognosis of HF patients treated with a contemporary medical regimen. Methods: Prospective study of 5314 HF patients and previously unknown DM during 9 years. Their mean age was 71.8 ± 7.9 years, 53.0% were women, and 50.2% had non-systolic HF. During a median follow-up of 56.9 ± 18.2 months, 68.9% of the patients died, 88.6% were hospitalized for HF, and 1519 (27.3%) developed new-onset DM. We propensity-matched those 1519 HF patients with DM, with 1519 HF patients non-diagnosed with DM. Results: The age- and sex-adjusted incidence (per 100 HF patients/years) of DM in HF patients was 3.20, higher in women and in patients with non-systolic HF (p < 0.01). Patients with HF and DM and those with a mean HbA1c > 7.0% presented an increased mortality (HR of death [CI 95%]: 2.44 [1.68-3.19] and, HR: 2.56 [1.77-3.35], respectively), mainly due to an increased cardiovascular mortality (HR ≥ 2.40 [1.46-3.34]) (P < 0.001). The rate of hospitalization, of 30-day readmissions, and the number of visits were higher among HF patients with DM or with HbA1c > 7.0% (p < 0.001). These relationships of DM and its poor metabolic control with prognosis were maintained, independently of the gender, the type of HF (systolic or, non-systolic), the comorbidities, and the medication used (P < 0.01). Conclusion: New-onset diabetes mellitus and its poor metabolic control (HbA1c > 7.0%) are associated with a increased mortality and morbidity of patients with heart failure. © 2012 Elsevier Ireland Ltd.

Romero S.P.,Hospital Universitario Puerto Real | Andrey J.L.,Hospital Universitario Puerto Real | Garcia-Egido A.,Hospital Universitario Puerto Real | Escobar M.A.,Hospital Universitario Puerto Real | And 4 more authors.
International Journal of Cardiology | Year: 2013

Objective: To assess the effect of the commencement of metformin therapy (CMet) on the prognosis of patients with newly diagnosed heart failure (HF) and new-onset diabetes mellitus (DM) treated with a contemporary medical regimen. Methods: Prospective study of 1519 HF patients with DM during 9 years. Mean age was 71.7 +/- 7.8 years, 817 (53.8%) were women, and 780 (51.3%) had preserved systolic function. During a median follow-up of 56.9 +/- 18.2 months, 1045 patients (68.8%) died, 1344 (88.5%) were hospitalized for worsening HF, 593 (39.0%) did not CMet, and 391 of the patients CMet (42.2%) had a mean HbA1c = < 7.0%. No case of lactic acidosis due to metformin was observed. We propensity-score matched 592 patients who CMet with another 592 patients non-CMet. Results: CMet was associated with a decreased mortality (HR [CI 95%]:.85 [.82-.88]), mainly due to a reduced cardiovascular mortality (HR:.78 [.74-.82]), and with a lower hospitalization rate (HR:.81 [.79-.84]). Nevertheless, CMet was not associated with an improved prognosis of HF patients with a mean HbA1c = < 7.0%. These relationships of CMet with prognosis were maintained, independently of the gender, the type of HF (systolic or, non-systolic), the comorbidities, and the medication used (P <.01). Conclusion: Metformin therapy is associated with a reduced mortality of heart failure patients with new-onset diabetes mellitus, mainly due to a decreased cardiovascular mortality, and with a lower hospitalization rate. Nevertheless, CMet was not associated with an improved prognosis of HF patients with a mean HbA1c = < 7.0%. © 2011 Elsevier Ireland Ltd.

Remon-Rodriguez C.,Hospital Universitario Puerto Real | Ganga P.L.Q.,Hospital Universitario Puerto Real
Nefrologia | Year: 2011

Studies that have analyzed survival between haemodialysis and peritoneal dialysis have showed heterogeneous outcomes for both techniques, and often confusing, also dependent on many factors. For this reason, it is necessary to know if there are real differences between the two treatments, to put the scientific evidence as a fundamental pillar in the choice of treatment, along with the clinical circumstances of individual patients, preferences and lifestyle of these. A comparative review of survival among dialysis techniques cannot avoid a basic methodological characteristics or attributes, such as appropriate designs such as observational studies with large cohorts, with incidents and no prevalent populations, with "intent to treat analysis", survival analysis and multivariate analysis with adjustments to the main comorbidity. We studied the nine classical main studies (incidents before 2002), presenting similar conclusions: there are no major differences between the techniques outcomes. When performing a stratification and ad-justment for comorbidities, peritoneal dialysis has a equivalent or better prognosis in the nondiabetic group, less comorbidity and younger, almost all the publications, and haemodialysis in diabetics, older and more comorbid groups. The recent studies (including incidents after 2002), concluding a similar behavior for the survival HD: DP. Similarly, age and comorbidity influence the patient's outcomes almost identical to previous studies. In the last decade has seen an improvement in the prognosis of patients on dialysis, more pronounced in PD patients, both in the U.S., and Europe, Australia and in Spain (Andalusia analysis also). Finally, by multivariate analysis, we can show that patient survival on dialysis is much more influenced by conditions at the beginning of the treatment, as age, presence of diabetes or cardiovascular disease, rather than the type of technique of dialysis. © 2011 Revista Nefrología.

Tibaldi G.,Centro Studi e Ricerche in Psichiatria | Salvador-Carulla L.,PSICOST Research Association | Garcia-Gutierrez J.C.,Hospital Universitario Puerto Real
Current Clinical Pharmacology | Year: 2011

Treatment adherence is related to "self-regulation" of prescribed drugs. Patients organise their drug intake around their own priorities, which may be very different from prescribers' priorities, since most of the patients value theirpersonal concerns and/or their social roles more than the benefits of a prescribed treatment. A gap exists between patients'and professionals' views. This gap is mainly related to patients' health beliefs and physicians' attitudes. A number ofstrategies can help professionals overcome gaps between their treatment options for depression and schizophrenia and the"real world" alternatives shared by the lay public, patients, their relatives, and political stakeholders. These strategiesinclude integrated care and recovery, family engagement, and the development of a mutualistic patient/physicianrelationship with the adoption of advance directives and appropriate guidelines that incorporate the patient's choices. Theeffective implementation of these combined strategies within the person-centred care model empowers patients tocollaborate with mental health professionals and their families in making complex health care choices. Barriers to thisprocess include factors affecting the control, contact and communication facets of the patient/physician relationship. © 2011 Bentham Science Publishers Ltd.

Diaz-Alersi R.,Hospital Universitario Puerto Real | Navarro-Ramirez C.,Hospital Universitario Puerto Real
Medicina Intensiva | Year: 2014

Patients with acute respiratory distress syndrome may require high positive end-expiratory pressure (PEEP) levels, though the optimum level remains to be established. Several clinical trials have compared high PEEP levels versus conventional PEEP. Overall, although high PEEP levels improve oxygenation and are safe, they do not result in a significant reduction of the mortality rates. Nevertheless, some metaanalyses have revealed 2 situations in which high PEEP may decrease mortality: When used in severe distress and when PEEP is set following the characteristics of lung mechanics. Five studies have explored this latter scenario. Unfortunately, all of them have small sample sizes and have used different means to determine optimum PEEP. It is therefore necessary to conduct studies of sufficient sample size to compare the treatment of patients with severe acute respiratory distress syndrome, using a protective ventilation strategy with high PEEP guided by the characteristics of lung mechanics and ventilation with the protocol proposed by the ARDS Network. © 2013 Elsevier España, S.L. and SEMICYUC.

This article discusses basic features of nutritional support in critically-ill patients: general indications, the route of administration and the optimal timing for the introduction of feeding. Although these features form the bedrock of nutritional support, most of the questions related to these issues are lacking answers based on the highest grade of evidence. Moreover, progresiprospective randomized trials that might elucidate some o f these questions would probably be incompatible with good clinical practice. Nevertheless, nutritional support in critically-ill patients unable to voluntarily meet their own nutritional requirements is currently an unquestionable part of their treatment and care and is essential to the successful management of their illness. © 2011 Sociedad Española de Medicina Intensiva, Critica y Unidades Coronarias (SEMICYUC) and Elsevier España, S.L.

Bover J.,Fundacio Puigvert | Perez R.,Hospital Infanta Leonor | Molina M.,Hospital Santa Maria Del Rosell | Benavides B.,Hospital Universitario Puerto Real | And 3 more authors.
Nephron - Clinical Practice | Year: 2011

Background: Cinacalcet reduces intact parathyroid hormone (iPTH), Ca and P serum levels in patients with secondary hyperparathyroidism (SHPT). Methods: This Spanish, multicenter, observational, retrospective study collected data from SHPT dialysis patients 12 weeks before and up to 72 weeks after starting cinacalcet in clinical practice. Results: Data from 428 patients with uncontrolled SHPT despite receiving standard of care (29% with baseline iPTH 501-800 pg/ml; 51% with >800 pg/ml) were collected. Percentages of patients within National Kidney Foundation Kidney Disease Outcomes Quality Initiative targets at baseline and 72 weeks were: iPTH, 0 versus 32.5% (p < 0.05); Ca, 40.1 versus 50% (p < 0.05); P, 47.7 versus 53.8% (p = 0.162). Vitamin D sterol use decreased from 53.3% at baseline to 36.7% at 72 weeks (p < 0.05). The mean ± SD cinacalcet dose at 72 weeks was 44.0 ± 25.8, 51.7 ± 31.3 and 57.1 ± 37.0 mg for patients with baseline iPTH 301-500, 501-800 or >800 pg/ml, respectively. The main adverse reactions were nausea (5.4%), dyspepsia (5.1%) and vomiting (3.7%). Conclusions: The introduction of cinacalcet improved the routine clinical management of SHPT in a large cohort of Spanish dialysis patients. Cinacalcet is effective and well tolerated regardless of disease severity, and maintains its efficacy over 72 weeks. Copyright © 2010 S. Karger AG, Basel.

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