[Accreditation in health care]. / Akkreditáció az egészségügyben.

Besides the rapid development of healing procedures and healthcare, efficiency of care, institutional performance and safe treatment are receiving more and more attention in the 21st century. Accreditation, a scientifically proven tool for improving patient safety, has been used effectively in healthcare for nearly a hundred years, but only started to spread worldwide since the 1990s. The support and active participation of medical staff are determining factors in operating and getting accross the nationally developed, upcoming Hungarian accreditation system. However, this active assistance cannot be expected without the participants' understanding of the basic goals and features of the system. The presence of the ISO certification in Hungary, well-known by healthcare professionals, further complicates the understanding and orientation among quality management and improvement systems. This paper aims to provide an overview of the history, goals, function and importance of healthcare accreditation, and its similarities and differences regarding ISO certification.

Decreased circulating anandamide levels in preeclampsia.

The endocannabinoid system has a key role in female reproduction, including implantation, decidualization and placentation. A growing number of studies indicate that placental and peripheral blood anandamide levels correlate closely with both spontaneous miscarriage and ectopic pregnancy. Anandamide has also been implicated in blood pressure regulation. In this study, we aimed to determine circulating anandamide levels in preeclampsia for the first time in the literature. Forty-three preeclamptic patients and 71 healthy pregnant women were involved in this case-control study. Serum anandamide concentrations were determined by high-performance liquid chromatography-mass spectrometry technique. Serum total soluble fms-like tyrosine kinase-1 (sFlt-1) and biologically active placental growth factor (PlGF) levels were measured by electrochemiluminescence immunoassay. For statistical analyses, nonparametric methods were applied. Serum levels of anandamide were significantly lower in preeclamptic patients than in healthy pregnant women (0.75 (0.44-1.03) ng ml(-1) vs. 1.30 (0.76-2.0) ng ml(-1), P<0.001). Preeclamptic patients had significantly higher sFlt-1 levels (12,121 (7963-18,316) pg ml(-1) vs. 2299 (1393-3179) pg ml(-1), P<0.001) and significantly lower PlGF concentrations (71.2 (39.2-86.4) pg ml(-1) vs. 256.8 (181.1-421.0) pg ml(-1), P<0.001) as compared with healthy pregnant women. Serum anandamide concentrations did not correlate with serum levels of sFlt-1 and PlGF in our healthy pregnant and preeclamptic groups. In conclusion, we demonstrated for the first time in the literature that serum anandamide concentrations are decreased in women with preeclampsia. However, the cause and consequence of this observation remain to be determined.

Increased placental expression of cannabinoid receptor 1 in preeclampsia: an observational study.

BACKGROUND: The endocannabinoid system plays a key role in female reproduction, including implantation, decidualization and placentation. In the present study, we aimed to analyze cannabinoid receptor 1 (CB1), CB2 and fatty acid amid hydrolase (FAAH) expressions and localization in normal and preeclamptic placenta, in order to determine whether placental endocannabinoid expression pattern differs between normal pregnancy and preeclampsia. METHODS: Eighteen preeclamptic patients and 18 normotensive, healthy pregnant women with uncomplicated pregnancies were involved in our case-control study. We determined CB1, CB2 and FAAH expressions by Western blotting and immunohistochemistry in placental samples collected directly after Cesarean section. RESULTS: CB1 expression semi-quantified by Western blotting was significantly higher in preeclamptic placenta, and these findings were confirmed by immunohistochemistry. CB1 immunoreactivity was markedly stronger in syncytiotrophoblasts, the mesenchymal core, decidua, villous capillary endothelial and smooth muscle cells, as well as in the amnion in preeclamptic samples compared to normal pregnancies. However, we did not find significant differences between preeclamptic and normal placenta in terms of CB2 and FAAH expressions and immunoreactivity. CONCLUSIONS: We observed markedly higher expression of CB1 protein in preeclamptic placental tissue. Increased CB1 expression might cause abnormal decidualization and impair trophoblast invasion, thus being involved in the pathogenesis of preeclampsia. Nevertheless, we did not find significant differences between preeclamptic and normal placental tissue regarding CB2 and FAAH expressions. While the detailed pathogenesis of preeclampsia is still unclear, the endocannabinoid system could play a role in the development of the disease.

Comparison of placental growth factor and fetal flow Doppler ultrasonography to identify fetal adverse outcomes in women with hypertensive disorders of pregnancy: an observational study.

BACKGROUND: Hypertensive disorders of pregnancy and intrauterine growth restriction (IUGR) are leading causes of maternal and perinatal morbidity and mortality. Failure to detect intrauterine growth restriction in women at high risk has been highlighted as a significant avoidable cause of serious fetal outcome. In this observational study we compare fetal flow using Doppler ultrasonography with a new test for placental growth factor (PlGF) to predict fetal adverse events. METHODS: Eighty-nine women with hypertensive disorders of pregnancy (24 with chronic hypertension, 17 with gestational hypertension, 12 with HELLP syndrome, 19 with preeclampsia and 17 with superimposed preeclampsia) were enrolled. A single maternal blood sample to measure free PlGF (Alere Triage) taken before 35 weeks of pregnancy was compared to the last Doppler ultrasound measurement of fetal flow before delivery. PlGF was classified as normal (PlGF≥100 pg/ml), low (12

B7 costimulation and intracellular indoleamine-2,3-dioxygenase expression in peripheral blood of healthy pregnant and pre-eclamptic women.

PROBLEM: We determined the frequency of activated (CD11b+) monocytes expressing B7-1, B7-2, B7-H1, and B-7H2, and that of T cells and T helper cells expressing CD28, CTLA-4, PD-1, and ICOS in peripheral blood samples from normal pregnant (NP) and pre-eclamptic (PE) women. We also examined the intracellular expression of indoleamine-2,3-dioxygenase (IDO). METHOD OF STUDY: We measured the expression of the above markers using flow-cytometry in peripheral blood samples from 20 NP and 20 PE women in the third trimester. RESULTS: The frequency of B7-1 and B7-2 expressing activated monocytes and that of IDO expressing T-lymphocytes was lower in PE than in NP. CONCLUSION: Lower expression of B7-1 and B7-2 proteins on peripheral monocytes in PE might indicate a secondary regulatory mechanism in response to the ongoing systemic maternal inflammation. IDO plays an important role in the pregnancy-specific immune tolerance, and might be a contributing factor in the pathogenesis of PE.

Evaluation of a rapid and simple placental growth factor test in hypertensive disorders of pregnancy.

The aim of this study was to investigate the diagnostic accuracy of the Triage placental growth factor (PlGF) assay, together with its prognostic efficiency in determining the need for preterm delivery in all forms of hypertensive disorders of pregnancy. A total of 130 pregnant women with a diagnosis of preeclampsia (PE: 23), HELLP syndrome (20), superimposed preeclampsia (SIPE: 17), chronic hypertension (CHT: 25), gestational hypertension (GHT: 18) and 27 normotensive pregnant controls were enrolled in this case-control study. A single blood sample was taken between 22 and 34 weeks of gestation, and the plasma was analyzed for PlGF using the Alere Triage PlGF assay. The PlGF levels found in all hypertensive disorder groups differed significantly from those observed in controls. There was a highly significant difference in PlGF concentrations between women with a pregnancy duration <35 weeks and controls. Using a gestational age-dependent threshold of 5% of normal, a positive PlGF test predicted delivery before 35 weeks in 93.7% of hypertensive women and delivery before 37 weeks in 90.5% of hypertensive women. A positive PlGF test identified the following proportions of hypertensive patients: 95.7% (PE), 95.0% (HELLP syndrome), 82.4% (SIPE), 60.0% (CHT) and 44.4% (GHT). A positive PlGF test was associated with a significantly shorter duration of pregnancy (hazard ratio of 3.43 adjusted for the gestational age at the time of sample collection and hypertension with proteinuria). In conclusion, PlGF concentrations are significantly lower in all hypertensive disorders. A positive test using the Triage PlGF assay at 22-34 weeks of gestation predicts delivery before 37 weeks in women with both proteinuric and non-proteinuric hypertensive disorders of pregnancy.

Circulating levels of thrombospondin-1 are decreased in HELLP syndrome.

BACKGROUND: Preeclampsia is characterised by an imbalance of circulating pro- and anti-angiogenic factors. The syndrome of haemolysis, elevated liver enzymes and low platelet count (HELLP) develops mostly on the ground of preeclampsia, and one of its important features is the severe disturbance of the coagulation system, intravascular coagulopathy. Thrombospondin-1 (TSP-1) is derived from the endothelium and platelets, and exerts potent pro-thrombotic and anti-angiogenic effects. Our aim was to determine, whether its circulating levels are altered in preeclampsia and in HELLP syndrome. METHODS: We enrolled 45 pregnant women with early-, 43 with late-onset preeclampsia, 21 with HELLP-syndrome, 45 with uncomplicated pregnancy and 20 non-pregnant controls in our case-control study. TSP-1 levels were determined by enzyme-linked immunosorbent assay. RESULTS: Circulating TSP-1 levels were lower in HELLP syndrome compared to all other study groups, while they were unaltered in preeclampsia compared to the control groups. There was a significant positive linear correlation between TSP-1 levels and platelet count in HELLP syndrome. In patients with more severe HELLP syndrome, TSP-1 levels were significantly lower compared to women suffering from a milder form of HELLP syndrome. CONCLUSIONS: Circulating thrombospondin-1 levels are decreased in HELLP syndrome and they seem to reflect disease severity, lower levels representing a more severe state. Nevertheless, despite its potent anti-angiogenic effect, our results suggest that circulating TSP-1 does not play a significant role in the pathogenesis of preeclampsia.