[Synthetic indicator of compliance with standards for Quality Units of health centers and multicenter prospective pilot study]. / Indicador sintético de cumplimiento de estándares para Unidades de Calidad de centros sanitarios y estudio de pilotaje prospectivo multicéntrico.

BACKGROUND AND OBJECTIVE: In Spain, Quality Units play a key and unique role in advising healthcare centers on the methodology of healthcare quality. The objectives of the study were to develop computer algorithms to obtain a synthetic indicator of standard compliance for Quality Units and to pilot its functioning in these units. MATERIALS AND METHODS: The Excel program was used to establish evaluation algorithms, and quantitatively interrelate and weight various categories of standards, as a computer evaluation tool, to build a continuous improvement cycle system, and offer a global synthetic indicator of compliance. The tool was tested in a prospective multicenter pilot study, in which coordinators of Quality Units from different health centers and care settings participated, to evaluate the usefulness of the tool and compliance with the standards, in addition to analyzing the content validity of each standard. RESULTS: The formulas for the structured computer algorithms were developed, consecutively, in a «PLAN-DO-CHECK-ACT¼ improvement cycle for the 9 categories of standards, resulting in a single synthetic indicator of compliance. Twenty-one Quality Units participated in the piloting. The overall average compliance rate for the synthetic indicator was 55.63% with differences between centers (P=.002) and between categories (P<.0001), but not by autonomous communities (P=.86) or by areas (P=.97). Content validity was ensured through the variable of «understanding¼ of the standards (P<.001), and through their «justification¼ with documentary evidence (P<.001). CONCLUSIONS: The computer tool with the synthetic indicator have allowed for the evaluation of standard compliance in Quality Units of healthcare centers.

[Development and validation of standards for quality units of health centers]. / Desarrollo y validación de estándares para unidades de calidad de centros sanitarios.

OBJECTIVE: In Spain, the Quality Units advise health centres, services and professionals on the methodology of continuous improvement of the quality of care. A system based on good practice standards could provide these units with a tool to improve their results and value their work. The objective was to develop, agree on and validate standards, to properly guide and orient the functions, results and continuous improvement of the Quality Units in health centers. MATERIAL AND METHODS: A qualitative-quantitative, prospective and cross-sectional study was carried out, applying the Metaplan method, the e-Delphi technique and a simulation study. The participants were coordinators of these units, belonging to 14 Spanish Autonomous Communities and distributed in four experts' panels. They agreed on the standards to be used and evaluated the different types of validity. RESULTS: The 204 standards proposed by the scientific committee were reduced to 157 with Metaplan, to 110 with e-Delphi, and to 96 with the committee's final review (87.3% consensus, content validity). The construct validity showed a Cronbach's alpha >0.7 (P<.001); the validity of content was reaffirmed in the simulation workshop (80% "understood" each other, P<.001; and there was "documentary evidence" in 84%, P<.001); face validity was accepted (75% "related to quality dimensions", P<.001); and the validity of the criteria was verified with a sensitivity of 84.2%, a specificity of 98.3%, and a kappa index of 0.84. CONCLUSIONS: Valid standards have been developed for Quality Units in health centers.

[The use of antithrombotic drugs in patients with chronic atrial fibrillation in a local health area]. / Utilización de fármacos antitrombóticos en pacientes con fibrilación auricular crónica en un área sanitaria comarcal.

BACKGROUND: The objective of the study is to assess the degree of ambulatory use of prophylactic antithrombotic therapy in patients with chronic atrial fibrillation (CAF) in a county health area. PATIENTS AND METHODS: A cross-sectional, prospective survey carried out in patients admitted at a community-hospital, detected 44 patients with CAF. RESULTS: The inappropriateness of anti-thrombotic therapy (48%) was associated with no having a previous echocardiography (p < 0.004), not being controlled in a hospital (p < 0.02) and in patients without information on the cardioembolic risks (p < 0.0007). CONCLUSIONS: The antithrombotic prophylaxis is scarcely used in patients affected by CAF in the county health area studied.

[Colonic obstruction in Whipple's disease]. / Oclusión de colon en la enfermedad de Whipple.

A patient with Whipple's disease presented with low intestinal obstruction and hemorrhage due to mesenteric retraction which was attributed to intra-abdominal enlarged lymph nodes. Ultrastructural findings included abundant intracellular bacilli. This complication of Whipple's disease has not been previously described and should be listed in the differential diagnosis of colonic obstruction.

[Endocarditis due to Candida albicans with peripheral arterial embolism and a cerebral mycotic aneurysm in an IV drug addict]. / Endocarditis por Candida albicans con embolismo arterial periférico y aneurisma micótico cerebral en adicto a drogas por vía parenteral.

Endocarditis due to Candida albicans (EC) is a rare cause of endocarditis in IV drug addicts (IVDA). Its diagnostic is usually difficult and high peripheral embolization is characteristic, and could affect big vessels. The case of a female patients (IVDA) 21 years old is discussed, who showed bilateral iliofemoral embolism and cerebral hemorrhage due to mycotic aneurysm breakage in a EC. These two complications appeared during an EC episode are exceptional. We insist in the importance of the echographic images in the suspicion diagnosis of EC.

[Severe leukopenia and thrombocytopenia and transient acquired hypogammaglobulinemia in a patient with infectious mononucleosis]. / Leucopenia y trombocitopenia intensas e hipogammaglobulinemia adquirida transitoria en un paciente con mononucleosis infecciosa.

A 30-year-old male with infectious mononucleosis by the Epstein-Barr virus who presented severe neutropenia and thrombocytopenia and type IgG acquired transitory hypogammaglobulinemia as complications during the acute period of the disease is presented. Although the etiopathogenesis of these phenomena is usually associated with an autoimmune basis, the antiplatelet and antileukocyte antibodies were negative. A bibliographic revision of the hematologic alterations of this disease was carried out and it was observed that the combination of the complications described has not been previously referred, thus, the present case may be the first observation with these characteristics.

[Usefulness of echocardiography in heart insufficiency: a prospective study of 100 patients]. / Utilidad de la ecocardiografía en la insuficiencia cardíaca: estudio prospectivo sobre 100 pacientes.

We prospectively evaluated 100 patients with heart failure, grades III and IV of the NYHA who were admitted to our Internal Medicine Service. In all cases a clinical diagnosis previous to the recording of the echocardiogram was made to evaluate the contributions of the latter. In 26 patients the echocardiogram gave information which had not been anticipated from the history and basic studies. This information resulted in a change of diagnosis in 21 cases and in the addition of a diagnosis with therapeutic and/or prognostic implications in 5 cases. It also permitted an approach to pathogenesis in the subgroup with preserved systolic function (36%), which were categorized as having diastolic dysfunction. On the other hand, the echocardiogram permitted the definition of the group of elderly patients, with heart failure and without previously known heart disease, which we considered as having senile heart disease.

[Bacteremia in the patient with liver cirrhosis. Prospective study of 61 episodes]. / Bacteriemia en el paciente con cirrosis hepática. Estudio prospectivo de 61 episodios.

We prospectively evaluated 61 episodes of bacteremia in 54 patients with hepatic cirrhosis, representing 9% of the overall number of bacteremic episodes in adult patients seen in our center during the study period. Spontaneous bacteremia represented 46% of all episodes (virtually always in patients with ascites), followed by the urinary origin (30%). Gram negative organisms were isolated in 71% of episodes. 43% of these were hospital-acquired 25% of patients had spontaneous peritonitis. Among other complications of bacteremia there were shock (28%), renal failure (24%), and disseminated intravascular coagulation (6%). The mortality rate due to sepsis was 28%, that due to complications of cirrhosis by itself was 20%, and that of nonrelated diseases was 8%. Shock and renal failure secondary to bacteremia were independent predictors of a poor prognosis.

[Bacteremia secondary to decubitus ulcer]. / Bacteriemia secundaria a úlceras de decúbito.

We have prospectively evaluated 16 episodes of bacteremia induced by decubitus ulcers. The most commonly isolated microorganisms were Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa and Bacteroides fragilis. Bacteremia was polymicrobial in 5 cases (31%). Most ulcers were already present at the time of admission, but bacteremia developed within the hospital in 13 patients. In 3 patients, ulcers did not show local features of infection. The initial antibiotic therapy was satisfactory in 13 cases. Mortality rate directly associated with bacteremia was 18%, but the overall mortality rate was 62%. We did not identify data permitting a reliable prediction of the findings of blood culture; therefore, the initial empirical therapy should be active against Staphylococcus aureus, Pseudomonas, enteric Gram-negative bacilli and anaerobes including Bacteroides fragilis.

Spontaneous bilateral chylothorax: uniform features of a rare condition.

A 67-yr-old woman was admitted with dyspnoea, chest and neck pain and swelling of both supraclavicular fossae and the neck. Chest X-ray showed bilateral pleural effusions. Thoracocentesis yielded a milky fluid with a high triglyceride level. Four previously published cases had similar clinical manifestations. The pathophysiology is discussed.