Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors.

INTRODUCTION: Medication errors are frequent at care transition points and can have serious repercussions. Study objectives were to examine the frequency/type of reconciliation errors at hospital admission and discharge and to report on the drugs involved, associated risk factors and potential to cause harm in a healthcare setting with comprehensive digital health records. MATERIAL AND METHODS: A prospective observational 2-year study was conducted in the Internal Medicine Department of a regional hospital. The best possible medication history was obtained from different sources by clinical pharmacists and compared with prescriptions at admission and discharge. The frequency and type of reconciliation errors were studied at admission and discharge, evaluating risk factors for their occurrence and their potential to cause harm. RESULTS: The study included 814 patients (mean age: 80.2 years). At least one reconciliation error was detected in 525 (64.5%) patients at admission, with a mean of 2.2 ± 1.3 errors per patient and in 235 (32.4%) patients at discharge. Drug omission was the most frequent reconciliation error (73.6% at admission and 71.4% at discharge); 39% of errors at admission and 51% at discharge had potential to cause moderate or severe harm. The risk of error at admission was higher with more pre-admission drugs (p < 0.001) and, among patients with reconciliation errors, the number of errors was significantly higher in those receiving more drugs pre-admission or with more comorbidities. The risk at discharge was higher in patients with more drugs prescribed at discharge (p = 0.04) and in those with a longer hospital stay (p = 0.03). CONCLUSIONS: Medication reconciliation procedures are required to minimise medication discrepancies and enhance patient safety. Integration of patient health records across care levels is necessary but not sufficient to prevent errors.

Cardiovascular risk assessment in rheumatoid arthritis: impact of the EULAR recommendations on a national calibrated score risk index.

OBJECTIVES: To evaluate the impact of the application of the EULAR task force recommendations in the cardiovascular (CV) risk assessment of rheumatoid arthritis (RA) patients according to a national calibrated SCORE. METHODS: Two hundred and one consecutive RA patients seen at the rheumatology outpatient clinics of the University Hospital 'San Cecilio', Granada, Southern Spain, were studied. Information on demographic, classic CV risk factors, history of CV events and disease clinical features were obtained. Both the systematic coronary risk evaluation (SCORE) risk index and the modified SCORE (mSCORE) following the EULAR recommendations were performed. RESULTS: Based on the classic CV risk factors the mean ± standard deviation SCORE was 2.2 ± 2.6 (median 2). Twenty-two (11%) patients were above the threshold of high risk for the Spanish population. Following the EULAR recommendations 52 of the 124 patients (41.93%) initially classified as having intermediate risk were reclassified as having high CV risk. Therefore, the mean mSCORE was 3.3 ± 4 (median 3) and, due to this, 74 (36.8%) patients were above the threshold of high CV risk for the Spanish population. As expected, patients who had experienced CV events were older, had more CV risk factors and higher mSCORE than those without CV events. CONCLUSIONS: These observations support the claim that the mSCORE should be specifically adapted to the population to be assessed. However, the use of additional tools should be considered in an attempt to fully identify high-risk RA patients.

[20 cases of carcinoid tumors of the digestive system]. / Estudio de 20 casos de tumores carcinoides de aparato digestivo.

We are presenting 20 cases of carcinoid tumors of the digestive system. We shall evaluate: age, sex, localization and histopathology, symptomatology, therapeutics and evolution. Appendicular carcinoids were the most frequent: 13 cases. All were chance findings in the histopathological examination of surgically resected appendix in eight acute appendicitis and in four laparotomies for other reasons. Histologically the classic pattern predominated, with formation of cellular nidus, with the cells being argentaffin. These characteristics permit classifying them as tumors derived from the embrionary middle intestine. No appendicular carcinoid developed metastasis. The extirpation was always curative, partially due to the small size and to the facility of obstructing the appendicular lumen. Four cases were gastric carcinoids. Their cells grouped forming trabeculas or were arranged irregularly, being negative for argyrophil and argentic tinction (tumors derived from the cephalic intestine). Two of them presented associated peptic ulcer (histamine implication). The two remaining ones came for studies related to asthenia, anorexia and weight loss, and in both cases hepatic metastasis without carcinoid syndrome were found. Two less frequent localizations were Meckel's diverticulum and ampulla of Vater. The latter developed hepatic metastasis without carcinoid syndrome. The only carcinoid syndrome was found in a patient who died due to adult respiratory distress without having localized the primary tumor.

[Determining factors in the success of the treatment of ureteral lithiasis by ESWL]. / Factores determinantes en el éxito del tratamiento de la litiasis ureteral mediante LEOC.

Shock-wave extracorporeal lithotripsy (SWEL) is admittedly the choice method for most ureteral calculi (UC). Treatment of 1.674 UC was carried out with a Lithostar (Siemens). Endourologic support manoeuvres (ESM) were used in 11.7% patients. To determine their statistical influence on treatment's result variables such as site, size, calculus density, obstruction and functionality of the renal unit, as well as presence of ureteral malformation, were analyzed. With an average of 1.3 sessions (9100 waves) success rate was 91.8% cases. Only the variables of size, obstruction and function showed statistical significance, thus identifying through a multistep logistic regression test the subgroup of calculi less likely to succeed (calculi > 1 cm2, with severe uropathy and functional annulment or delay). Complication were rare (7.5%) and minimally relevant. We conclude than SWEL is the first choice treatment for UC regardless the location. Ureteroscopy (UR) should be considered as the first option particularly in distal (iliopelvic ureter), obstructive calculi and those of difficult radiological study.

[An echocardiographic study of the aortic root in ankylosing spondylitis]. / Estudio ecocardiográfico de la raíz aórtica en la espondilitis anquilosante.

The inflammatory condition in ankylosing spondylitis (AS) may affect cardiac structures, being the aortic valve mostly studied. Several studies regard the existence of a subaortic ridging as specific for AS. Our objective was to assess abnormalities in the aortic root in AS using echocardiography and its relation to HLA B-27 and clinical parameters of the disease. Thirty patients with no clinical, radiographic or electrocardiographic evidence of cardiovascular disease were studied by monodimensional, bidimensional and Doppler echocardiography. After an initial ultrasound examination to detect subclinical cardiac abnormalities, aortic root dimensions were measured at the aortic annulus, at the tip of the cusps and 1 cm above the cusps. The existence of subaortic ridging was assessed using bidimensional echocardiography. As clinical parameters were estimated duration of AS, sacroiliac joint X-ray involvement and activity of disease. The results are compared with those in a control group of thirty healthy people with same age, sex and corporal surface. No statistical differences were observed in the mean values of aortic root dimensions between the two groups; in patients with AS were not seen significant differences in the echocardiographic measurements related to clinical parameters or HLA B-27. Only in one patient was observed the characteristic subaortic ridging (4%, NS compared to control group). We conclude, in contrast to other authors, that in patients with AS without cardiovascular disease echocardiographic examination of aortic root does not detect significant abnormalities.

[Amyloid angiopathy as a clinico-pathological entity to consider in the differential diagnosis of any hemorrhagic cerebrovascular accident]. / La angiopatía amiloide como entidad clínico-patológica a valorar en el diagnóstico diferencial de todo accidente cerebro vascular hemorrágico.

Intracerebral hemorrhages represent about 10% of the whole of vascular cerebral accidents. According to different authors, the incidence of cerebral amyloid angiopathy varies between 5-10% and up to 20-30% of all primary non-traumatic intracerebral hemorrhages. This incidence was analyzed in our environment. A retrospective study was carried out on 403 patients, 203 of them were analyzed between 1990-91 and the other 200 between 1992-3. Age, arterial tension, relapses and localization were taken as criteria for a diagnosis. For the statistical analysis, Student's T-test was used for quantitative variables, while square Chi with Yates' correction was used for qualitative variables. Ischemic cerebral accidents (90.5% of the total) are more frequent than hemorrhagic cerebral accidents, which represent 5.7%. 3.7% were not registered. Therefore, it was suspected cerebral amyloid angiopathy in 1.4% of all vascular cerebral accidents. This represents 26.1% of the total of hemorrhagic patients. Different variables from groups of hemorrhagic vascular cerebral accidents were compared to those caused by amyloid cerebral angiopathy and significant statistics were found with respect to localization in the cerebral hemispheres (p < 0.01). Neither age, nor arterial tension or relapses were significant. Amyloid cerebral angiopathy as a cause of hemorrhagic cerebrovascular accident is and entity to be considered in the diagnosis of these patients. By using clinical criteria and others of localization through complementary explorations, a diagnosis for guessing such a process can be determined.

Intestinal permeability in patients with ankylosing spondylitis and their healthy relatives.

Patients with AS were previously found to have increased intestinal permeability using the 51Cr-EDTA resorption test. In order to discover whether this alteration has taken place prior to, or as a consequence of the disease, we studied the intestinal permeability to 51Cr-EDTA in 20 patients with AS, 65 of their healthy relatives, and 25 normal volunteers. We also considered the HLA B27 antigen, the serum immunoglobulin A levels, the disease activity, the existence of peripheral arthritis, the ESR, the CRP values and the intake of drugs at the time of study. Gut permeability was found to have increased in the patients and their healthy relatives compared to the control group. No difference in gut permeability was found between patients and relatives regardless of whether they had the HLA B27 antigen or not. The increased intestinal permeability in the patients had no relation to the disease activity, to the presence of peripheral arthritis or to the intake of NSAIDs. Gut permeability was shown to bear no relation to IgA levels, ESR or CRP. Our findings suggest that the increase in gut permeability in AS patients and their relatives is a primary defect and may be an aetiologic factor in this disease.

Trace elements in drug addicts.

We studied trace elements (zinc, copper, magnesium, iron, and lithium) by atomic absorption spectrophotometry in the plasma and erythrocytes of 120 subjects: 20 healthy controls and 100 parenteral drug addicts (69 heroin and 31 heroin + other drugs). Plasma Zn and intraerythrocytic Zn and Fe were decreased, whereas plasma and intraerythrocytic Cu were significantly increased in the group of drug addicts with respect to the healthy controls. Moreover, a period of abstinence longer than 10 days was associated with lower plasma levels of Zn and Li in subjects who had taken drugs shortly before they were examined. The presence of serological markers against HBV and HIV did not seem to influence the behavior of the trace elements in blood.

Differences in gallstone structure in primary common bile duct lithiasis and gallbladder lithiasis.

Some differences between gallbladder lithiasis and primary common bile duct lithiasis are described. Microbiological cultures and biochemical analyses were carried out on the bile of two groups of patients: 27 suffering from gallbladder and 5 from primary common duct lithiasis. The microstructure and composition of gallstones were also examined by polarized light microscopy and X-ray diffraction. Women predominated in gallbladder lithiasis but not in primary common duct lithiasis group (P less than 0.05) and body weight was higher in the former group (P less than 0.02). Primary common duct lithiasis patients had a higher, although not significant, incidence of duodenal diverticulosis (P = 0.15), and a higher incidence of E. coli-positive cultures in bile (P less than 0.001). No significant difference in the biochemical composition of the bile was found between the groups. Brown pigment stones predominated in primary common duct lithiasis, while cholesterol stones did in gallbladder and secondary common duct lithiasis (P less than 0.0001). Stones formed in the gallbladder generally show linear, radial growths of cholesterol crystals, while those from the common duct present a polystratified, concentric deposition of microgranules composed mainly of pigmentary salts. These differences should be taken into account as additional criteria in the differential diagnosis between primary and secondary common duct lithiasis, as the classical criteria for diagnosing of the former greatly underestimate its actual incidence. The distinction between primary and secondary common duct lithiasis is of practical significance, since each entity requires different treatment.

Zinc and liver cirrhosis.

We have measured zinc levels in serum and urine of healthy controls, patients with liver cirrhosis and patients with cirrhosis and hepatic cancer. In patients with ascitic fluid, we also measured zinc, total protein, albumin and alpha 2-globulin. Basal measurements were performed in blood drawn at 8.00, before the intravenous administration of 8 mg zinc in the form of zinc sulphate. Serum levels were measured at various intervals to a total time of 24 h after overload, and total urine was collected for zinc determinations 24 h before and 24 h after overload. Under basal conditions, cirrhotic patients had lower serum levels and higher rates of urinary excretion of zinc than controls. After overload, blood levels of zinc fell more rapidly in cirrhotic patients than in controls, the former group showing no concomitant rise in urinary zinc excretion, thus suggesting an organic deficit in this trace element. In ascitic fluid, the concentration of zinc was positively correlated with protein content.