[Not Available]

INTRODUCTION

The purpose of this article is to present a model for clinical risk management based on technological and organisational advances with proven effect. Designed for a single clinical Unit, the model is open to other notification systems and health care clinical units.

MATERIAL AND METHOD

The model has three implementation phases. The first phase involved studying the existing safety system and objectively measured the culture of patient safety. The second phase included development and implementation of a system for the management of critical incidents with creation of a team of specialists. The third phase was the development of the technological and organizational base for horizontal and vertical integration, for internal and external training, and opening the system to other clinical units.

RESULTS

We found an unstructured, non-confidential, potentially punitive model of clinical risk management without efficacy criteria. There was an unsatisfactory safety culture level for all of the evaluation issues. The introduction of a system for critical incident management gave the basis for the optimization and evaluation of the patient safety related processes.

CONCLUSIONS

Our model for clinical risk management is a simple, useful and efficient example for introducing a patient safety strategy in a hospital clinical unit.

Umbilical venous blood flow measurement: accuracy and reproducibility

Umbilical venous blood flow could be considered a direct and physiological measurement of vascular placental function, representing the quantity of oxygen and nutrients reaching the fetus. The advent of high-technology ultrasound and pulsed Doppler has overcome some of the limitations of early studies. Indeed, Doppler measurement of umbilical venous blood flow has been found to be accurate when compared with several gold standards for in-vivo flow calculation. Nevertheless, small errors in volume flow components, the vessel area and the mean velocity, result in large errors in the calculation of volume flow. Therefore, technique standardization is of paramount importance. Validation studies in animal models have demonstrated accurate venous blood flow measurements by estimating the vessel's cross-sectional area from perpendicular views of longitudinal sections of free-floating portions of the cord. On the other hand, estimation of the mean velocity from the maximum velocity, rather than using the intensity-weighted mean velocity, is less software-dependent and more clearly defined, yielding estimates with more predictable and systematic errors. By adhering to stringent methodological recommendations, umbilical venous blood flow calculation has moderate to good intra- and interobserver reproducibility. Having been found to be accurate and reproducible, further studies are required to establish the clinical value of umbilical vein flow measurement.

Reference ranges for uterine artery mean pulsatility index at 11-41 weeks of gestation

OBJECTIVES

To construct gestational age (GA)-based reference ranges for the uterine artery (UtA) mean pulsatility index (PI) at 11-41 weeks of pregnancy.

METHODS

A prospective cross-sectional observational study was carried out of 20 consecutive singleton pregnancies for each completed gestational week at 11-41 weeks. UtAs were examined by color and pulsed Doppler imaging, and the mean PI, as well as the presence or absence of a bilateral protodiastolic notch, were recorded. Polynomials were fitted by means of least-square regression to estimate the relationship between the mean UtA-PI and GA.

RESULTS

A total of 620 women were included. A second-degree polynomial (Log(e) mean UtA-PI = 1.39 - 0.012 x GA + GA(2) x 0.0000198, with GA measured in days), after a natural logarithmic transformation, was selected to model our data. There was a significant decrease in the mean UtA-PI between 11 weeks (mean PI, 1.79; 95(th) centile, 2.70) and 34 weeks (mean PI, 0.70; 95(th) centile, 0.99). It then became more stable up until 41 weeks (mean PI, 0.65; 95(th) centile, 0.89).

CONCLUSIONS

The mean UtA-PI shows a progressive decrease until the late stages of pregnancy. Reference ranges for mean UtA-PI may have clinical value in screening for placenta-associated diseases in the early stages of pregnancy, and in evaluating patients with pregnancy-induced hypertension and/or small-for-gestational age fetuses during the third trimester.

[Analysis and predictor of delays in the suspicion and treatment among hospitalized patients with pulmonary tuberculosis]

BACKGROUND AND OBJECTIVES

Sometimes tuberculosis diagnosis is missed at hospital admission. Delayed diagnosis of active pulmonary tuberculosis among hospitalized patients could to contribute to nosocomial transmission. The objective of this study was to define the occurrence and associated patient risk factors among hospitalized patients with delayed diagnosis of respiratory tuberculosis.

METHODS AND PATIENTS

A retrospective chart review was undertaken between 1995 and 2002 on all patients with pulmonary tuberculosis. Time intervals between admission, diagnosis and treatment of tuberculosis were determined. Epidemiological and clinical features were evaluated for their effect on these time intervals.

RESULTS

Among 149 patients newly diagnosed to have active pulmonary TB, the diagnosis was initially missed in 102 (68% [95% CI, 61 to 75%]) of all hospitalized patients, of whom 66 (65% [95% CI, 56 to 74%]) were smear positive. Treatment was initiated after a week or more in 62 (42% [95% CI, 34% to 50%]) of all patients, of whom 34 (55% [95% CI, 43 to 67%])) were smear positive. Age >or= 60 years (OR 3.17 [95% CI; 1.27 to 7.87]; p = 0.013), presence of chronic lung disease (OR 2.99 [95% CI; 1.21 to 7.38]; p = 0.017), negative sputum AFB smear (OR 4.51 [95% CI; 1.34 to 15.16]; p = 0.015) and absence of hemoptysis or melanoptysis (OR 2.96 [95% CI; 1.18 a 7.41]; p = 0.020), were independently associated with delays.

CONCLUSIONS

The diagnosis and treatment of hospitalized patients with pulmonary tuberculosis is often delayed because absence of clinic suspicion owing to old age, chronic lung disease or atypical presentations and slow confirmation by culture. Improved clinical acumen, development of rapid diagnostic tests, and the institution of early empiric therapy are desirable objectives to improve the tuberculosis control.

[Non-convulsive status with hemianopsia and ictal headaches: an uncommon manifestation of parieto-occipital epilepsy]

INTRODUCTION

Parieto-occipital epilepsy is uncommon disease that usually occurs with positive symptoms such as illusions, visual hallucinations. The pericital headache, with or without migraine-type characteristics, is common symptoms (amaurosis, hemianopsia) are rare.

CLINICAL CASE

A 21 year-old woman with a previous medical history of Rendu-Osler disease was admitted to the hospital because of migraine-type headache. Examination revealed homonymous hemianopsia which had not been previously observed. During admission, brief episodes of ocular and cephalic deviation to the left were observed. An electroecephalogram showed frequent seizures arising from the right parieto-occipital region. Symptoms disappeared with antiepileptic drug treatment.

CONCLUSION

We report a case of parieto-occipital epilepsy with headache and hemianopsia as ictal symptoms. Differential diagnosis must be done basically with migraine attacks. This type of epilepsy may be underdiagnosed.

[Neuroanesthetic practice in Catalonia. Results of a survey done on 2003]

INTRODUCTION

Health system planning requires the precise knowledge of the activity performed. We present the neuroanesthesic activity results in Catalonia during 2003.

METHODS

A prospective and cross-sectional survey was performed for 14 randomised days during 2003. All hospitals practicing anaesthesia in Catalonia took part in the survey. Data on characteristics of patients, anaesthetic techniques and type of procedure were included.

RESULTS

6909 neuroanesthetic procedures performed in Catalonia in 2003 (95% IC 6022-7847), a 1.28% of total surgical activity. A 74% of procedures were done in the public hospitals and a 26% in private hospitals. Patients mean age was 48 years old (95% IC 45.5-50.6). Scheduled procedures were 79.7%. The most frequent interventions were: Spine surgery 40.1 %; craniotomies for tumour resection 24.1%, for haemorrhage o trauma 7.2% and for aneurysms or AVM surgery 2.3%; ventricular shunts 2.6%. Mean duration of craneotomies for tumour resection was 287 -/+95 min. All patients were distributed postoperatively in a conventional recovery room (55.8 %), in a monitored care unit (19.2%) or in an intensive care unit (24.9 %). Craniotomy patients were admitted to an intensive care unit (41.6%), a monitored care unit (33.7%) or a conventional recovery room (24.7%).

CONCLUSIONS

About seven thousand Neurosurgical procedures were performed in Catalonia in 2003, in public (73.6%) and private (26.4%) hospitals. Spine surgery and craniotomies for tumour resection were the most frequently performed interventions. Craniotomy patients were mainly submitted to an ICU or a Monitored care unit.

Modulation by insulin-like growth factor I of the phosphatase PTEN in astrocytes

Characterization of intracellular pathways underlying the pleiotropic actions of insulin-like growth factor-I (IGF-I) on brain cells is incomplete. We analyzed IGF-I signalling on astrocytes through the canonical phosphatidylinositol 3-kinase (PI3K)/Akt pathway and focused on possible changes in PTEN, a phosphatase that modulates IGF-I signalling by inhibiting Akt activation and, in turn is positively regulated by PI3K. After exposure of astrocytes to IGF-I, PTEN mRNA and protein levels were reduced and its phosphatase activity diminished. Inhibition of PTEN involved activation of a PI3K/protein kinase C (PKC) pathway that decreased in a proteasome-dependent step the levels of the transcription factor Egr-1, a key regulator of PTEN levels in astrocytes, causing decreased binding of Egr-1 to the PTEN promoter. Enhanced mitogenesis in PTEN siRNA-transduced astrocytes after IGF-I suggested that reduced PTEN may be a permissive factor for the mitogenic activity of IGF-I. Subsequent recovery of reduced PTEN required also activation by IGF-I of PI3K to recruit in this case protein kinase A (PKA) which stimulated Egr-1 levels and, consequently PTEN synthesis. Because basal levels of PTEN in astrocytes are also governed by PI3K, IGF-I appears to modulate PTEN in astrocytes by redirecting its homeostasic control through PI3K in a timed fashion.

[Fourth branchial cyst within the thyrohyoid membrane: a difficult differential diagnosis with mixed laryngocele]

We present a case of a 62-year-old female patient with a right latero-cervical mass and an enlarged arytenoepiglottic fold, that caused voice disturbances. Computed tomography of the neck depicted an unilocular and homogeneous well-defined cyst located in the right parapharyngeal space that extended through the thyrohyoid membrane. It was initially diagnosed of mixed laryngocele. During surgical resection, no connexion between the lesion and laryngeal ventricle was detected, so the final diagnosis was branchial cyst. We discuss the pathogenicity and clinical, radiological and histological findings that facilitate differential diagnosis between mixed laryngocele and branchial cysts, mainly those derived from the second and fourth clefts. The radiological and histological findings in both lesions may be similar, so only the communication with the larynx, or its absence, can solve diagnostic doubts, course.

Ear, nose and throat manifestations in pemphigus vulgaris

BACKGROUND

Pemphigus vulgaris (PV) is an autoimmune disease characterized by mucocutaneous intraepithelial blisters and pathogenic autoantibodies against desmoglein 3. There are two clinical forms: mucosal (MPV) and mucocutaneous (MCPV). The frequency of ear, nose and throat (ENT) involvement in PV is not clearly defined. Only a few isolated individual cases have been reported.

OBJECTIVES

The objective of our study was to determine the incidence of ENT involvement in patients with PV.

PATIENTS

We studied prospectively all 16 patients diagnosed with PV and treated in the Department of Dermatology of the University Clinic of Navarra between 2001 and 2005. They were 10 cases of MPV and six cases of MCPV. All patients were evaluated for ENT manifestations by endoscopic examination.

RESULTS

Of the 16 patients, 13 presented with throat symptoms (81%), 12 pharyngeal (75%) and seven laryngeal symptoms (44%). Fourteen patients (88%) had active PV lesions on endoscopic evaluation (eight patients had active lesions on both pharyngeal and laryngeal mucosa, four had PV lesions only on laryngeal mucosa and two had PV lesions on pharyngeal mucosa). Laryngeal lesions were most commonly present in MPV patients. The frequency of nasal symptoms (38%) was lower than active PV lesions (62%) found on ENT examination. Oral symptoms and oral active PV lesions were the most frequent findings (94%). Only three patients with MCPV showed erosions on the external auditory canal.

CONCLUSIONS

As ENT endoscopy allows more extensive areas of mucosa to be examined than simple visual inspection, we recommend that it be included in the examination of all patients with PV. By obtaining more complete information concerning the extent of the disease, a more accurate diagnosis can be made, better choice of drug and dose may be decided and, ultimately, response to treatment may be improved.

Diagnostic yield and safety of capsule endoscopy

INTRODUCTION

the capsule endoscopy (CE), from his approval, has become a first line diagnostic procedure for the study of the small bowel disease. The aim of this study is to report our experience since the implantation of this technique in our hospital.

MATERIAL AND METHODS

retrospective review of the CE undertaken in Department of Endoscopy. There was gathered in every case the age, sex, motive of consultation, previous diagnostic procedures, capsule endoscopy findings and complication of the technique. One took to end a descriptive and analytical analysis.

RESULTS

there was achieved a total of 416 explorations in 388 patients. The obscure gastrointestinal bleeding was the most frequent indication (83.30%) followed by suspected Crohn s disease (7.5%). Angiodisplasia was the endoscopic lesion more frequently detected (42.2%), especially, in patients with digestive bleeding of obscure origin (OR 3.13 p < 0.001), followed by the flebectasia (10.6%) and the ulcer suspicious of Crohn s disease (9.9%). The global diagnostic yield as for the detection of injuries was 77.34% with a case of "not defecation of the capsule" and therefore need of laparotomy.

CONCLUSIONS

the capsule endoscopy is a technique consolidated and as his potential is known, his indications are extended. The obscure gastrointestinal bleeding is the most frequent indication and the angiodisplasia the most identified injury. Once known his diagnostic yield, larger studies are needed that assess the influence of capsule endoscopy on clinical outcoumes.

Cerebrospinal Fluid Composition Modifications after Neuroendoscopic Procedures

Normal saline solution is currently used as the ventricular irrigation fluid during neuroendoscopic procedures. The aim of this study is to determine the alterations in the cerebrospinal fluid (CSF) composition after neuroendoscopic interventions. Twenty nine patients who underwent a neuroendoscopic procedure under general anaesthesia were studied. Temperature inside the cerebral ventricle was measured and samples of CSF were taken to determinate oxygen and carbon dioxide partial pressures, pH, base excess, ionised calcium, standard bicarbonate, glucose, sodium, potassium, magnesium, total calcium, proteins, chlorine and osmolality before initiating the irrigation and after the neuronavigation. Patient demographics, neuronavigation time, total fluid volume used and temperature of the irrigation solution and complications that appeared in the first 24 hours were collected. Mean age of the patients was 42+/-18 years. The mean neuronavigation time was 21.5+/-15.4 minutes. The mean amount of saline solution used for irrigation was 919.6+/-994.7 mL. All the values studied in the CSF, except osmolality, showed significant variations. There was a significant correlation between the CSF variation of pH, oxygen and carbon dioxide partial pressures, base excess, standard bicarbonate, glucose and total calcium with respect to the total volume of irrigation solution, but not with respect to the neuronavigation time. A cut-off point of 500 mL of irrigation solution (sensitivity 0.7; specificity 0.87) was related with a CSF pH decrease greater than 0.2. The use of saline as irrigation solution during neuroendoscopic procedures produces important changes in CSF.