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Introducción: Debido al riesgo que conlleva la exposición a radiación ionizante, se han establecido los principios de protección radiológica, con el propósito de regular las actividades que involucran su uso. Uno de estos principios es la justificación de los exámenes, es decir, la indicación del examen cuando exista la posibilidad de que éste entregue información en beneficio del paciente. Esto implica que dicho examen se evalúe en cuanto a su rendimiento, de manera que exista evidencia que indique su capacidad de entregar la información necesaria para la indicación específica del paciente. Revisión: Para evaluar el rendimiento de los exámenes imagenológicos, con el fin de orientar su uso como herramienta diagnóstica en las distintas indicaciones odontológicas, se ha usado el modelo de Eficacia Diagnóstica descrito por Fryback y Thornbury en 1991.En odontología, el uso de la tomografía computarizada de haz cónico (TCHC) ha aumentado debido a sus ventajas como herramienta diagnóstica. Aún así, son pocas las investigaciones en altos niveles del modelo de Eficacia Diagnóstica -más relacionados con características aplicables al paciente--y muchas las investigaciones en bajos niveles -más relacionado con calidad técnica y de exactitud diagnóstica-. Conclusiones: La evidencia del rendimiento de la TCHC en bajos niveles puede generar una idea equivoca sobre sus indicaciones, dando la impresión de que cuenta con respaldo científico suficiente que justifica su uso. Es necesaria investigación enfocada en el beneficio de los pacientes con el uso de TCHC para las distintas indicaciones en odontología. (AU)

Introduction: Due to the risk of exposure to ionizing radiation, principles of radiation protection have been established, with the aimto regulate activities that involve the use of ionizing radiation. The principle of justification means that the indication of the exam must be associated to the possibility of providing information for the benefit of the patient. The indication of an exam that results in a benefit for the patient entails the evaluation of the exam in terms of its performance. This evaluation should demonstrate the exam has ability to deliver the necessary information for the specific need of the patient. Review: The Diagnostic Efficacy model, described by Fryback and Thornbury in 1991, is used to evaluate the performance of imaging tests, in order to guide its use as a diagnostic tool in different dental indications. In dentistry, the use of TCHC has increased due to the advantages as a diagnostic tool. Still, there are few investigations at high levels of the Diagnostic Efficacy model - related to characteristics that involve the patient - and many investigations at low levels - more related to technical quality and diagnostic accuracy. Conclusions: Evidence of the performance of CBCT at low levels generates a misunderstanding about its use, giving the impression that CBCT has sufficient scientific support to justify its use. Currently, the evaluation of the performance of the TCHC has focused on evaluating the lowest levels of this model, the image quality and the diagnostic precision, although evidence at this level remains limited. Research focusing on the benefit of patients with the use of CBCT for the different indications in dentistry is needed. (AU)

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BACKGROUND: The prevalence of malnutrition in older persons depends on the healthcare setting. In recent years, hospital-based case management programs (CM Programs) targeting individuals in the community with chronic multimorbidity and high use of hospital resources (admissions or emergency visits) have been developed in many countries to reduce the need for complex health care. The objective of this study was to assess the prevalence of risk of malnutrition, using the Short Form of the Mini-Nutritional assessment, of community dwelling patients included in a chronic CM Program. Factors associated with malnutrition risk were also explored. METHODS: Patients included in a hospital-based integrated CM Program for older persons at high risk for hospital readmission after an index admission were studied. MNA-SF was used at program inclusion to assess the risk of malnutrition. An array of factors potentially associated with malnutrition were explored (including feeding route, use of dental prosthesis, dysphagia, consistency of foods, specific therapeutic diets, use of oral nutritional supplements, polypharmacy, falls, and other diseases and geriatric syndromes). RESULTS: 791 participants were included, mean age 79.8 years, 50.1% females. Risk of malnutrition was present in 44.9%. Participants at risk of malnutrition were more frequently female, had a lower BMI, were less likely to be fed orally and used more nutritional supplements. They also had a higher prevalence of dysphagia, needing changes in food consistency or using specific therapeutic diets, and had dementia or cancer more frequently. They also showed a higher need for palliative care. CONCLUSIONS: Risk of malnutrition in patients included in a CM Program is higher than in non-selected community dwelling older individuals. This information may help inform screening policies in similar populations at risk of hospital readmission.

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Objetivos: La administración rutinaria de oxígeno en el infarto agudo de miocardio(IAM) es una práctica sometida a debate especialmente tras la aparición de una revisión Cochrane de oxígeno vs aire que muestra un importante, aunque no significativo, aumento de la mortalidad (RR: 3,03, IC 95%: 0,93-9,93) en el grupo tratado con oxígeno y concluye que debe realizarse un ensayo clínico aleatorio que ofrezca evidencia definitivas. El objetivo de este estudio es conocer extensión del uso de la oxigenoterapia en el IAM no complicado y las creencias de los clínicos al respecto. Método: Se uso un método combinado de invitación por correo electrónico a una muestra teórica de profesionales que atienden al IAM y un cuestionario a cumplimentaron-line en la web. Resultados: El 86% de los encuestados usan rutinariamente el oxígeno en el IAM no complicado, casi la mitad (44%) cree que mejora el dolor y más de la mitad (54%)cree que tiene algún efecto beneficioso sobre la mortalidad. Casi el 29% de los participantes desconocen las recomendaciones de la guías al respecto. Se aprecian mínimas diferencias en las creencias de los clínicos según su especialidad. Conclusiones: La oxigenoterapia en IAM es una práctica muy extendida, que se justifica en parte por la creencia de que mejora el dolor o/y la mortalidad. La creencia deberá ser tenida en cuenta en los diseños de investigación futuros (AU)

Background and objective: The routine administration of oxygen in acute myocardial infarction (AMI) is a practice open to debate, particularly after a Cochrane review of oxygen vs air showed a no significant but considerable increase in mortality for oxygen-treated patients (relative risk 3.03; 95% confidence interval, 0.93-9.93). The reviewers concluded that a randomized controlled trial was needed to provide definitive evidence. The aim of this study was to know the prevalence of use of oxygen therapy in uncomplicated AMI and the beliefs of physicians about this therapy. Material and methods: Two recruitment methods were combined. Participants were found either through e-mails sent to a theoretical sample of physicians treating AMI, in which they were given a link to the web-based survey, or by means of a posted link to the online survey. Results: Eighty-six percent of the respondents treat AMI with oxygen therapy. Nearly half (44%) believe it relieves pain and over half (54%) believe it reduces mortality. Nearly 29% are unfamiliar with guidelines for oxygen therapy in AMI .Scant differences were found between medical specialties. Conclusions: Oxygen therapy is widely used in AMI. Physicians justify their use by referring to the by a belief that it reduces pain and mortality. Beliefs should be taken into account in designing future research (AU)

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OBJECTIVES: We performed a systematic review of randomized controlled trials to compare combined general-epidural anesthesia, followed by postoperative epidural analgesia, and general anesthesia followed by postoperative parenteral analgesia without epidural analgesia in patients undergoing thoracoabdominal surgery. Outcome measures considered were mortality, length of stay in hospital and in the intensive care unit, analgesia, and morbidity. MATERIAL AND METHODS: We performed a systematic search of online databases (MEDLINE, EMBASE, the Cochrane Controlled Trials Registry and the metaRegister of clinical trials at http://www.controlled-trials.com/mrct/ mrct info es.asp). We also hand-searched the literature. Authors were contacted when deemed necessary. RESULTS: A total of 30 trials (4294 patients) were analyzed. Combined anesthesia showed significant advantages in relation to 2 variables: respiratory failure (odds ratio, 0.71; 95% confidence interval [CI], 0.58 to 0.87) and analgesia on the first day after surgery (weighted mean difference, -6.91 95% CI, -9.46 to -4.36). No significant differences were found in the other variables. CONCLUSIONS: Combined anesthesia provides better analgesia and is associated with fewer cases of postoperative respiratory failure. No significant differences were found in mortality, length of stay in hospital, or other morbidity variables.

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OBJETIVOS: Revisión sistemática de ensayos clínicos aleatorizadospara comparar anestesia combinada generalepiduralseguida de analgesia postoperatoria epidural, conanestesia general seguida de analgesia postoperatoriaparenteral pero no epidural, en pacientes intervenidos decirugía toracoabdominal. Resultados valorados: mortalidad,estancia hospitalaria y en la Unidad de Críticos, analgesiay morbilidad.MATERIAL Y MÉTODOS: Búsqueda sistemática en basesde datos electrónicas (MEDLINE, EMBASE, The CochraneControlled Trials Registry y el metaregistro de ensayosclínicos: http://www.controlled-trials.com/mrct/mrct infoes.asp). Búsqueda manual a partir de la bibliografía de losartículos. Contacto con autores cuando se juzgó necesario.RESULTADOS: Analizados un total de 30 estudios (4.294pacientes). La anestesia combinada mostró ventajas significativasen 2 variables: insuficiencia respiratoria, OR(Odds Ratio) = 0,71 con un IC (intervalo de confianza al95%) de 0,58 a 0,87, y analgesia del primer día de postoperatorio:diferencia ponderada de medias –6,91 (IC de–9,46 a –4,36). En el resto de variables no se encontrarondiferencias significativas.CONCLUSIONES: La anestesia combinada aporta mejoranalgesia y presenta menos casos de insuficiencia respiratoriaen el postoperatorio. No se encontraron diferenciassignificativas en mortalidad, estancias hospitalarias y otrasvariables de morbilidad (AU)

OBJETIVES: We performed a systematic review ofrandomized controlled trials to compare combinedgeneral-epidural anesthesia, followed by postoperativeepidural analgesia, and general anesthesia followed bypostoperative parenteral analgesia without epiduralanalgesia in patients undergoing thoracoabdominalsurgery. Outcome measures considered were mortality,length of stay in hospital and in the intensive care unit,analgesia, and morbidity.MATERIAL AND METHODS: We performed a systematicsearch of online databases (MEDLINE, EMBASE, theCochrane Controlled Trials Registry and the metaRegisterof clinical trials at http://www.controlled-trials.com/mrct/mrct info es.asp). We also hand-searched the literature.Authors were contacted when deemed necessary.RESULTS: A total of 30 trials (4294 patients) wereanalyzed. Combined anesthesia showed significantadvantages in relation to 2 variables: respiratory failure(odds ratio, 0.71; 95% confidence interval [CI], 0.58 to0,87) and analgesia on the first day after surgery (weightedmean difference, -6.91 95% CI, -9.46 to -4.36). Nosignificant differences were found in the other variables.CONCLUSIONS: Combined anesthesia provides betteranalgesia and is associated with fewer cases ofpostoperative respiratory failure. No significant differenceswere found in mortality, length of stay in hospital, or othermorbidity variables (AU)

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La aproximación terapéutica a la intoxicación etílica aguda presenta algunos aspectos controvertidos. En este original se revisa su tratamiento mediante la búsqueda estructurada de la literatura publicada al respecto. Se analizan los trabajos hallados y se concluye una pauta a partir de la mejor evidencia disponible

Therapeutic approach to acute alcohol intoxication has some controversial aspects. In this original article, its treatment is reviewed by means of structured search of the literature published. The studies found are critically appraised and a guideline concluded better on the better evidence available

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OBJECTIVE: To determine the effects of intermittent flushing with heparin versus NaCl 0.9% solution on prevention of thrombotic events and infections in central venous catheters. METHOD: A systematic review of controlled trials, randomized or not, in whose intermittent flushing with heparin versus NaCl 0.9% in central venous catheters were compared was carried out. Any publication was excluded because of patients age, country or language. Studies were identified by computerised searches (MEDLINE and CINAHL 1996-2004, EMBASE Drugs and Pharmacology 1991-2004, Cochrane Library up 2005, ISI Web of knowledge 1990-2004), clinical trials metaregister http://www. controlled-trials.commrct/mrct_info_es.asp, and scanning references. RESULTS: Only two clinical trials, involving 94 patients, fulfilled inclusion criteria for obstruction. Methodological quality of trials was poor and heterogenicity was also very significant. It made impossible meta-analytical combination of results. No studies comparing heparin vs. NaCl 0.9% solution flushing in catheter-related infection prophylaxis were reported. CONCLUSIONS: Poor evidence supports effectiveness of intermittent heparin flushing vs. NaCl 0.9% solution, although methodological limitations and small sample size make these findings very inconsistent. In infection prophylaxis, there is no data allowing us to conclude if heparin flushing is more effective than NaCl 0.9% solution. More randomized clinical trials are needed.

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Objetivo: Estimar mediante una revisión sistemática si el selladointermitente con heparina es más efectivo que la solución deNaCl al 0,9% en la prevención de eventos trombóticos y de infeccionesen catéteres venosos centrales.Método: Se buscaron todos los estudios, aleatorizados ono, en los que se comparara sellado (flush) con heparina frentea NaCl 0,9% en pacientes portadores de catéteres venosos centrales.No se excluyó ningún artículo por edad de los pacientes,país, ni idioma de la publicación. Para la localización de losensayos se revisó Medline y CINAHL (1966-2004), EMBASEDrugs & Pharmacology (1991-2004), Cochrane Library, ISIWeb of Knowledge (1990-2004) y el meta-registro de ensayosclínicos http://www.controlled-trials.com/ mrct/mrct_info_es.-asp. Se realizó además seguimiento manual de las referencias.Resultados: Únicamente 2 trabajos, que incluyeron 94pacientes, cumplieron finalmente los criterios de inclusión paraobstrucción. La calidad metodológica de los ensayos revisados fuemuy baja y la heterogeneidad muy marcada, lo que no hizo posiblela combinación metaanalítica de los resultados. En infección,ninguno de los trabajos evaluó el sellado con heparina frente aNaCl 0,9%.Conclusiones: Los ensayos de efectividad en obstrucciónsugieren que el sellado con heparina es más efectivo que conNaCl 0,9%. Sin embargo, las limitaciones metodológicas de losensayos y su reducido tamaño muestral hacen que estos hallazgosdeban ser interpretados con suma cautela. En prevención de lainfección, no hay datos que permitan concluir si la heparina esmás efectiva que la solución de NaCl 0,9%. Son necesarios másensayos clínicos adecuadamente diseñados

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Objetivos. Se revisa el tratamiento antihipertensivo en los ancianos, los resultados en morbilidad y mortalidad con distintas terapias farmacológicas. Diseño. Revisión sistemática. Participantes. Se revisan los ensayos de ancianos -hipertensión- con resultados en morbimortalidad de Medline y en la base de datos de la colaboración Cochrane. Mediciones y resultados principales. Beneficio de tratamiento en pacientes ancianos medido como morbilidad (coronaria, cerebral) y mortalidad (general, cardiovascular y cerebrovascular). Resultados. Existe suficiente evidencia de que el tratamiento de la hipertensión es útil en los ancianos, aunque es dudosa la eficacia para ancianos de edad superior a 80 años. Mortalidad general: RR, 0,84 (0,75-0,94); morbilidad coronaria: RR, 0,80 (0,70-0,92). Para mayores de 80 años, mortalidad general; RR, 1 (0,86-1,17), y mortalidad cardiovascular: RR, 0,94 (0,75-1,18). No todos los grupos farmacológicos producen los mismos resultados en mortalidad y morbilidad. Los diuréticos son los que mejores resultados aportan sobre el resto de tratamientos farmacológicos. Sólo los diuréticos a dosis bajas mejoran la mortalidad cardiovascular y modifican la morbilidad cerebrovascular. Conclusiones. El tratamiento farmacológico en los ancianos hipertensos es beneficioso en términos de mortalidad y morbilidad. El tratamiento con diuréticos a dosis bajas, con o sin ahorradores de potasio, es el tratamiento electivo para la hipertensión en los ancianos (AU)

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OBJECTIVES: To describe the benefits of treatment for hypertension in the elderly, the most efficient drugs, those most widely used in clinical practice to reduce morbi-mortality taken from the literature. DESIGN: Systematic review. PARTICIPANTS: Review study in Medline and the Cochrane Collaboration database. The antihypertensive pharmacological treatment is described (diuretics high and low dosage, calcium channel blockers, ACE inhibitor, and beta-blockers) administered to elderly people and their outcomes in morbi-mortality. MEASUREMENTS AND MAIN RESULTS: Reduction in coronary and cerebral morbidity and general, cardiovascular and cerebrovascular mortality. RESULTS: There is evidence to suggest that treatment for hypertension is helpful in the elderly, although efficiency is doubtful in patients over 80 years old. For persons aged over 65 general mortality is RR = 0.84 (0.75-0.94) and coronary morbidity RR = 0.80 (0.70-0.92). For persons aged over 80 general mortality is RR = 1 (0.86-1.17) and cardiovascular mortality is RR = 0.94 (0.75-1.18). Not all pharmacological groups produce the same results in mortality and morbidity. Diuretics (low dosage) offer better results than the remaining treatments reducing cardiovascular mortality as well cerebrovascular morbidity. CONCLUSIONS: Treatment with drugs in hypertense elderly people is beneficial in terms of mortality and morbidity. Treatment with low dose diuretics, with or without potassium savers, is the elective treatment for hypertension in elderly patients.

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