Computerized pharmaceutical intervention to reduce reconciliation errors at hospital discharge in Spain: an interrupted time-series study.

WHAT IS KNOWN AND OBJECTIVE: It is well known that medication reconciliation at discharge is a key strategy to ensure proper drug prescription and the effectiveness and safety of any treatment. Different types of interventions to reduce reconciliation errors at discharge have been tested, many of which are based on the use of electronic tools as they are useful to optimize the medication reconciliation process. However, not all countries are progressing at the same speed in this task and not all tools are equally effective. So it is important to collate updated country-specific data in order to identify possible strategies for improvement in each particular region. Our aim therefore was to analyse the effectiveness of a computerized pharmaceutical intervention to reduce reconciliation errors at discharge in Spain. METHODS: A quasi-experimental interrupted time-series study was carried out in the cardio-pneumology unit of a general hospital from February to April 2013. The study consisted of three phases: pre-intervention, intervention and post-intervention, each involving 23 days of observations. At the intervention period, a pharmacist was included in the medical team and entered the patient's pre-admission medication in a computerized tool integrated into the electronic clinical history of the patient. The effectiveness was evaluated by the differences between the mean percentages of reconciliation errors in each period using a Mann-Whitney U test accompanied by Bonferroni correction, eliminating autocorrelation of the data by first using an ARIMA analysis. In addition, the types of error identified and their potential seriousness were analysed. RESULTS AND DISCUSSION: A total of 321 patients (119, 105 and 97 in each phase, respectively) were included in the study. For the 3966 medicaments recorded, 1087 reconciliation errors were identified in 77·9% of the patients. The mean percentage of reconciliation errors per patient in the first period of the study was 42·18%, falling to 19·82% during the intervention period (P = 0·000). When the intervention was withdrawn, the mean percentage of reconciliation errors increased again to 27·72% (P = 0·008). The difference between the percentages of pre- and post-intervention periods was statistically significant (P = 0·000). Most reconciliation errors were due to omission (46·7%) or incomplete prescription (43·8%), and 35·3% of which could have caused harm to the patient. WHAT IS NEW AND CONCLUSION: A computerized pharmaceutical intervention is shown to reduce reconciliation errors in the context of a high incidence of such errors.

[Effect of obesity on the morphology of the left ventricle]. / Influencia de la obesidad sobre la morfología del ventrículo izquierdo.

BACKGROUND: To analyze the relationship between obesity in its different degrees and the left ventricle morphology. PATIENTS AND METHODS: M-mode echocardiography was used to estimate the mass, wall thickness and internal dimension of left ventricle in 48 obese women with different degrees of obesity, defined according to the body mass index. 25 women with normal weight were used as controls. RESULTS: The body mass index was correlated with left ventricular mass, as well as with both the wall thickness of the left ventricle and its diastolic internal dimension. The abnormalities in the heart morphology increased according to the obesity degree, ranging from a 59% in the lesser obesity group up to a 100% in the more obese women. The incidence of the left ventricular hypertrophy determined by echocardiography also increased along with the body mass index, ranging from a 29% in the lesser degree of obesity women up to an 82% in the patients with a body mass index > 35 kg/m2. CONCLUSIONS: Obesity, even in its lowest degrees, shows frequent alterations in the heart morphology. This is related with a left ventricular mass increase and a higher incidence of the left ventricular hypertrophy. The left ventricular mass increase is due to an increase in the left ventricular walls thickness and also to a dilatation of its cavity.

[Recurrent syncope without angina: an uncommon presentation of coronary spasm]. / Síncope recurrente sin angina: una presentación infrecuente del espasmo coronario.

We report the case of a 64-year-old patient admitted for repetitive syncope as an isolated clinical manifestation probably due to coronary artery spasm. The patient had no history of previous cardiac disease, and was studied because of two nonspecific syncopes. Long-term electrocardiographic monitoring showed many episodes of transient ST segment elevation, associated with premature ventricular beats and runs of ventricular tachycardia. Coronary angiography during ergonovine infusion was performed to confirm the diagnosis. We discuss the incidence of coronary spasm provoking syncope and the need to establish a correct diagnosis in order to administer an effective therapy to the patient.

[The anomalous origin of the left common coronary trunk in the right sinus of Valsalva with an interarterial path. Apropos a case]. / Origen anómalo del tronco coronario común izquierdo en el seno de Valsalva derecho con trayecto interarterial. A propósito de un caso.

We present the case of an old patient with coronary artery disease and two previous myocardial infarctions, admitted to the hospital by syncopal episodes, in which the coronariographic study showed the ectopic origin of the left main coronary artery in the right sinus of Valsalva with anomalous course between the aortic and pulmonary arteries. In this case the initial coronariographic diagnosis and the therapeutical attitude (initially aggressive only in cases of interarterial course) was confirmed by mean of transesophageal echocardiography, showing a better topographical definition of the ectopic vessel aberrant course, although due to the high degree of left ventricular disfunction and the diffuse disease of distal vessels in this patient, CABG surgery was avoided. The angiographic feature is described and the transesophageal approach is remarked as a complementary diagnostic tool in the correct definition of the anomalous course.

[The spectral analysis of the P wave in patients with paroxysmal atrial fibrillation]. / Análisis espectral de la onda P en pacientes con fibrilación auricular paroxística.

INTRODUCTION AND OBJECTIVE: The aim of this study is to establish if patients with paroxysmal atrial fibrillation have an abnormal spectrum of the P wave. PATIENTS AND METHODS: Thirty-five patients with previous documented atrial fibrillation were compared with a control group of 29 patients. A signal-averaged ECG was performed using an ART-1200-EPX system, and a segment covering the last 75 ms of the P wave and the next 25 mg was analyzed in each of three orthogonal leads (X, Y, Z) and in a combined one (C). The area under the spectral curve between 20 and 50 Hz was divided by the area between 0 and 20 Hz (x 100 = AR50). RESULTS: Patients with paroxysmal atrial fibrillation had greater AR50 on leads Y (78.3 +/- 42.9 vs 54.4 +/- 14.8; p < 0.01) and C (82.2 +/- 52.1 vs 58.4 +/- 14.6, p < 0.05) when compared with the control group. In the subset of patients without structural heart disease AR50 in lead X was greater. The criterion "AR50 > 55 in lead Y" identified paroxysmal atrial fibrillation with a sensitivity of 77.1% and a specificity of 85%. CONCLUSIONS: This method may be useful to detect patients at risk for paroxysmal atrial fibrillation.

[Mitral valve insufficiency in acute myocardial infarction. Assessment with pulsed and coded Doppler color]. / Insuficiencia mitral en el infarto agudo del miocardio. Valoración con Doppler pulsado y codificado en color.

We studied 108 patients who sustained an acute myocardial infarction (AMI) by means of echocardiography, pulsed doppler (PD) and Doppler color flow imaging (CD). We evaluate the presence of mitral regurgitation (MR) and it relationship to the site of the AMI and also to the ventricular function. The incidence of MR was 50.92%, (55/108), it was detected in higher percentage when the AMI was inferior (61.8%) than when anterior (39.6%). The correlation with the ejection fraction (EF) was only significative when the AMI was anterior. The incidence of MR was 57.1% when the EF was below 25%. CD had better diagnostic capabilities independently of the site of the AMI, (48% vs 32.1% when the AMI was anterior and 76.1% vs 52.6% when it was inferior).

[Study of the influence of arterial pressure response to exertion on cardiac hypertrophy in patients with mild or moderate hypertension]. / Estudio de la influencia de la respuesta de la presión arterial al esfuerzo sobre la hipertrofia cardíaca en hipertensos ligeros y moderados.

In order to study the relationship between tensional response of an hypertensive patient to exercise and its cardiac repercussions, we have studied 42 essential hypertensive patients using echocardiography type M and 2D and exercise test. Patients were divided into two groups according to whether they had (GI) or not (GII) left ventricular hypertrophy. LVH was defined calculating left ventricular mass (LVM) or mean wall thickness (MWT). We have found significant correlations between tensional response and LVH, using only MWT as the index of LVH. This correlation was significant not only with maximum systolic arterial pressure but also with systolic arterial pressure in all intermediate charge stages. Evolution time of arterial hypertension significantly correlated with the degree of LVH according to MWT and less significantly with LVM. We conclude that the correlation between tensional response to exercise and cardiac hypertrophy is always higher when considering MWT as the index of LVH since the calculating the mass some other parameters are also present which hinder its significance and that correlation is established not only in the maximum exercise level.

[Study of blood pressure response to exertion in essential hypertension. Its modification with anti-hypertensive treatment]. / Estudio de la respuesta tensional al esfuerzo en hipertensos esenciales. Su modificación con el tratamiento antihipertensivo.

We have studied the effect of atenolol, xipamide, and verapamil in the control of effort tensional response in 54 patients suffering essential hypertension. A first effort test without treatment and a second after a one month treatment randomly assigned were performed in all patients, evaluating the tensional response at 30, 60 and 80 Watts of charge, maximum peak, and after five minutes in recovery. Atenolol significantly reduced (p less than 0.05) systolic arterial pressure and diastolic arterial pressure in every intermediate effort stage, maximum peak and post effort recovery, xipamide, also significantly reduced (p less than 0.05) the systolic hypertensive response at all different levels, however, the diastolic one did not reach any statistic significance. Verapamil at used doses did not modify neither systolic nor diastolic hypertensive response. The beneficial effect of beta-blockers is confirmed although we could not confirm the effect pointed out by other authors regarding calcium antagonists. Tensional control using xipamide was striking although there is some evidence to think that it can have a more important effect in the control than thiazide diuretics or amiloride.

[Importance of color-coded Doppler in a case of interventricular communication associated with fixed subaortic stenosis]. / Valor del Doppler codificado en color en un caso de comunicación interventricular asociado a estenosis subaórtica fija.

We describe a 10 year old girl with ventricular septal defect in whom bidimensional echocardiogram disclosed a membrane in the outflow tract of the left ventricle. Color Doppler found the presence of fixed subaortic stenosis.

[Hemodynamic and prognostic evaluation of total anomalous pulmonary venous return by means of echocardiographic measurement of the heart cavities]. / Valoración hemodinámica y pronóstica de la conexión anómala total de venas pulmonares mediante medición ecocardiográfica de las cavidades cardiacas.

The purpose was to demonstrate the relationship between cardiac cavity size, measured by echocardiography, with the hemodynamic overload and short-term prognosis in children with total anomalous pulmonary venous return (TAPVR). Ten children were studied; the age varied from 2 weeks to 4 months. The clinical and cardiac catheterization findings were compared with echocardiographic measurements. Children with a smaller left atrium showed severe pulmonary resistance and lower systemic cardiac output (P less than 0.01). Right ventricular dilatation was bigger when pulmonary resistance was more elevated (P less than 0.05). Children with end-diastolic diameter of the left ventricle less than 12.8 mm had lower cardiac output (P less than 0.01) and death rate was significantly elevated during the first twenty weeks of life (80%). Doppler-echocardiography is useful in the recognition of TAPVR type, as well as to evaluate the hemodynamic changes and detect the high risk group.

[Influence of left ventricular hypertrophy on its function in essential arterial hypertension. Analysis by Doppler echocardiography]. / Influencia de la hipertrofia del ventrículo izquierdo sobre su función en la hipertensión arterial esencial, análisis por ecocardiografia Doppler.

In order to evaluate the influence of left ventricular hypertrophy (LVH) on the function of this ventricle, twenty patients with essential arterial hypertension (EAH) were studied using Doppler echocardiography. Patients with diastolic blood pressure greater than 91 mmHg were included. Antihypertensive treatment was stopped 2 weeks before the study. None of them had any concomitant coronary artery disease nor kidney involvement. Left ventricular diameters, left ventricular mass (LVM), stroke volume, fractional shortening, mean velocity of circumferential shortening (Vcfr), mean velocity of circumferential relaxation, mean velocity of aortic flow and mean E and A velocities of mitral flow as well as the ratio of these velocities (E/A) were measured or calculated. With those values from the entire group, arithmetic means were calculated and the population was divided into two groups: those with values greater than the mean and those with values below the mean for each variable for comparative purposes. The relationship of the individual values was also calculated. The interventricular septum thickness and the left ventricular end diastolic diameter were proportional with diastolic blood pressure (p less than 0.05). The LVM values shown an inverse relationship to the fractional shortening (p less than 0.01), Vcfr (p less than 0.05) as well as end diastolic diameter of left ventricle (r = -0.889, p less than 0.01) and with the stroke volume (r = -0.861, p less than 0.01). The E/A ratio was proportional to the fractional shortening (p less than 0.05) and to Vcfr (r = 0.903). The A velocity of the mitral Doppler flow showed an inverse proportion to the Vcfr (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Aneurysm of the membranous interventricular septum. Study by Doppler echocardiography (color mapping in one of the cases)]. / Aneurisma del septum interventricular membranoso. Estudo por ecocardiografía Doppler (mapeo de color en uno de los casos).

Eight patients with aneurysm of the membranous interventricular septum (AMIS) were studied, in all of them the diagnosis was done by Doppler echocardiography (D-E). In all cases, the AMIS was visualized in left parasternal long and short axis views. In six of them by means of apical and subcostal four chamber views. The AMIS was identified as a bag-shaped echo at the level of the interventricular septum; it bulged into right ventricle during systole. Left-to-right shunt was demonstrated by pulsed wave Doppler in 5 patients and in another case with color flow mapping. AMIS has a mild hemodynamic repercussion as is the case with small ventricular septal defects. D-E offers diagnostic advantages, with high specificity if the AMIS is demonstrated in several views and the left-to-right shunt is recognized and quantified by Doppler technique.

[Hypertensive retinopathy in patients with aortic coarctation]. / Retinopatía hipertensiva en pacientes con coartación aórtica.

In order to assess the incidence and the determinants of hypertensive vascular changes in the retina of patients with coarctation of the aorta, fifty (37 male and 13 female) were analyzed. The mean age of the group was 18.7 +/- 10.3 years. No one had evidence of nephropathy. Different degrees of hypertensive retinopathy (Puig-Solanes classification) were observed in 54%. Of the patients, no one had papilledema. Retinal vascular damage was not related to either age or sex. The group of patients with retinal vascular lesions had a mean level of systolic arterial pressure higher than the group with normal retinas. Multivariant statistical analysis of the results permitted the identification of systolic arterial pressure higher than 150 mm Hg, age greater than 15 years and cardiomegaly as the three variables more frequently associated with retinal vascular lesions. Surgical correction of the aortic malformation resulted in normalization of both systolic and diastolic arterial pressures in 98% of the total number of patients as determined one year postoperatively. It is concluded that, in coarctation of the aorta, vascular damage of the retina appears to have an incidence that is similar to that observed in patients with other forms of systemic arterial hypertension. The development of these retinal lesions in patients with coarctation of the aorta would seem to be determined by the severity and duration of the hypertensive process.

[Effect of adenosine on P50 and its relation to 2,3-diphosphoglycerate]. / Efecto de la adenosina sobre la P50 y su relación con el 2,3-difosfoglicerato.

The effects of increasing doses of intravenous adenosine upon the dissociation haemoglobin curve (DHC) and its relation to the intraerythrocytic level of 2,3-diphosphoglyceric acid (2,3-DPG), were studied in 17 anesthetized dogs. The DHC moved significantly to the left in all dogs except at the dose of 120 micrograms/kg/min which induces a displacement to the right. These changes in the DHC were parallel to the intraerythrocytic levels of 2,3-DPG. We conclude that adenosine modifies the DHC, shifting it generally to the left, and that this effect seems to be related to a change in the intraerythrocytic level of 2,3-DPG.

[Echocardiographic recognition of endarteritis of the pulmonary artery in patent ductus arteriosus]. / Reconocimiento ecocardiográfico de endarteritis de arteria pulmonar en persistencia del conducto arterioso.

We described the echocardiographic signs of pulmonary endarteritis and the importance of Doppler study in three patients with patent ductus arteriosus. The diagnosis and follow-up of this complication with noninvasive study would avoid the exposure of the patient to danger of dislodging the vegetations with the catheter, during invasive procedures.

[Echocardiography and trivalvular infectious endocarditis in a heart without apparent previous cardiopathy]. / Ecocardiografía y endocarditis infecciosa trivalvular en corazón sin aparente cardiopatía previa.

The echocardiographic findings in a patient with infective endocarditis are reported. There was involvement the aortic, mitral, and tricuspid valves. The heart had no previous valvular disease. The M-Mode and two dimensional studies, showed presence of vegetations in the aortic, mitral, and tricuspid valves. We consider that the echocardiogram allows the detection of endocarditis in its early stage.