Characteristics and rates of infection by HIV in people receiving non-occupational post-exposure prophylaxis (nPEP) against HIV.

INTRODUCTION/OBJECTIVES: The use of non-occupational post-exposure prophylaxis (nPEP) emerges as a strategic intervention to reduce HIV infection risk following sexual encounters in our setting. Notwithstanding, there is a scarcity of contemporary data regarding adherence to this treatment, its effectiveness and tolerance. Our study aims to delve into these factors among individuals who have resorted to nPEP after high-risk sexual encounters. METHODS: We conducted a retrospective observational study of cases administered nPEP for HIV from 1 January 2018 to 31 December 2021 at a tertiary hospital in Madrid. The study included all adults over 18 years who sought care at the emergency department of the Fundación Jiménez Díaz Hospital following a risky sexual encounter and were subsequently recommended HIV nPEP treatment. RESULTS: 878 individuals received nPEP for HIV and underwent initial serological tests. Of these, 621 had comprehensive follow-ups. The prescribed regimen for all was raltegravir (RAL) 1200 mg combined with tenofovir/emtricitabine (TDF/FTC) 245/200 mg daily for 28 days. The study revealed a 1.1% rate (n=10) of previously undetected infection and a 0.16% (n=1) failure rate of nPEP. Regarding regimen tolerability, 5.6% (n=35) experienced symptoms linked to the treatment, yet none necessitated discontinuation of the regimen. On the contrary, six per cent (n=53) reported symptoms consistent with an STI during one of the medical visits; specifically, 4.4% had urethritis, and 1.6% had proctitis. CONCLUSION: nPEP with RAL/TDF/FTC demonstrates high efficacy and safety, contingent on proper adherence. There is an observed increase in STI prevalence in this cohort, with nearly half of the participants not engaging in appropriate follow-up after initiating nPEP.

Miniaturized flexible micro-tube plasma ionization source for the effective ionization of non-easily ionizable pesticides in food with liquid chromatography/mass spectrometry.

In this article, we have studied the potential of flexible microtube plasma (FµTP) as ionization source for the liquid chromatography high-resolution mass spectrometry detection of non-easily ionizable pesticides (viz. nonpolar and non-ionizable by acid/basic moieties). Phthalimide-related compounds such as dicofol, dinocap, o-phenylphenol, captan, captafol, folpet and their metabolites were studied. Dielectric barrier discharge ionization (DBDI) was examined using two electrode configurations, including the miniaturized one based on a single high-voltage (HV) electrode and a virtual ground electrode configuration (FµTP), and also the two-ring electrode DBDI configuration. Different ionization pathways were observed to ionize these challenging, non-easily ionizable nonpolar compounds, involving nucleophilic substitutions and proton abstraction, with subtle differences in the spectra obtained compared with APCI. An average sensitivity increase of 5-fold was attained compared with the standard APCI source. In addition, more tolerance with matrix effects was observed in both DBDI sources. The importance of the data reported is not just limited to the sensitivity enhancement compared to APCI, but, more notably, to the ability to effectively ionize nonpolar, late-eluting (in reverse-phase chromatography) non-ionizable compounds. Besides o-phenylphenol ([M - H]-), all the parent species were efficiently ionized through different mechanisms involving bond cleavages through the effect of plasma reagent species or its combination with thermal degradation and subsequent ionization. This tool can be used to figure out overlooked nonpolar compounds in different environmental samples of societal interest through non-target screening (NTS) strategies.

How different countries respond to adverse events whilst patients' rights are protected.

Patient safety is high on the policy agenda internationally. Learning from safety incidents is a core component in achieving the important goal of increasing patient safety. This study explores the legal frameworks in the countries to promote reporting, disclosure, and supporting healthcare professionals (HCPs) involved in safety incidents. A cross-sectional online survey was conducted to ascertain an overview of the legal frameworks at national level, as well as relevant policies. ERNST (The European Researchers' Network Working on Second Victims) group peer-reviewed data collected from countries was performed to validate information. Information from 27 countries was collected and analyzed, giving a response rate of 60%. A reporting system for patient safety incidents was in place in 85.2% (N = 23) of countries surveyed, though few (37%, N = 10) were focused on systems-learning. In about half of the countries (48.1%, N = 13) open disclosure depends on the initiative of HCPs. The tort liability system was common in most countries. No-fault compensation schemes and alternative forms of redress were less common. Support for HCPs involved in patient safety incidents was extremely limited, with just 11.1% (N = 3) of participating countries reporting that supports were available in all healthcare institutions. Despite progress in the patient safety movement worldwide, the findings suggest that there are considerable differences in the approach to the reporting and disclosure of patient safety incidents. Additionally, models of compensation vary limiting patients' access to redress. Finally, the results highlight the need for comprehensive support for HCPs involved in safety incidents.

The present and future of gastroenterology and hepatology: an international SWOT analysis (the GASTROSWOT project).

GASTROSWOT is a strategic analysis of the current and projected states of the different subspecialties in gastroenterology that aims to provide guidance for research, clinical, and financial planning in gastroenterology. We executed a consensus-based international strengths, weaknesses, opportunities, and threats (SWOT) analysis. Four general coordinators, six field coordinators, and 12 experts participated in the study. SWOTs were provided for the following fields: neurogastroenterology, functional gastrointestinal disorders, and upper gastrointestinal diseases; inflammatory bowel disease; pancreatology and biliary diseases; endoscopy; gastrointestinal oncology; and hepatology. The GASTROSWOT analysis highlights the following in the current state of the field of gastroenterology: the incidence and complexity of several gastrointestinal diseases, including malignancies, are increasing; the COVID-19 pandemic has affected patient care on several levels; and with the advent of technical innovations in gastroenterology, a well trained workforce and strategic planning are required to optimise health-care utilisation. The analysis calls attention to the following in the future of gastroenterology: artificial intelligence and the use of big data will speed up discovery and smarter health-care provision in the field; the growth and diversification of gastroenterological specialties will improve specialised care for patients, but could promote fragmentation of care and health system inefficiencies; and furthermore, thoughtful planning is needed to reach an effective balance between the need for subspecialists and the value of general gastroenterology services.

Frequency and estimated costs of ten low-value practices in the Spanish primary care: a retrospective study.

BACKGROUND: The frequency of low-value practices (LVPs) in the healthcare system is a worldwide challenge. This study aimed to evaluate the LVPs trend in Spanish primary care (PC), its frequency in both sexes, and estimate its related extra cost. METHODS: A multicentric, retrospective, and national research project was conducted. Ten LVPs highly frequent and potentially harmful for patients were analyzed (majority of them related to prescription). Algorithms were applied to collect the data from 28,872,851 episodes registered into national databases (2015-2017). RESULTS: LVPs registered a total of 7,160,952 (26.5%) episodes plus a total of 259,326 avoidable PSA screening tests. In adults, a high frequency was found for inadequate prescription of paracetamol antibiotics, and benzodiazepines . Women received more jeopardizing practices (p ≤ 0.001). Pediatrics presented a downward of antibiotic and paracetamol-ibuprofen prescription combination. The estimated extra cost was close to €292 million (2.8% of the total cost in PC). CONCLUSION: LVPs reduction during the analyzed period was moderate compared to studies following 'Choosing Wisely list' of LVPs and must improve to reduce patient risk and the extra related costs.

Why an Open Disclosure Procedure Is and Is not Followed After an Avoidable Adverse Event.

OBJECTIVE: The aim of the study was to analyze the relationships between factors that contribute to healthcare professionals informing and apologizing to a patient after an avoidable adverse event (AAE). METHODS: A secondary study based on the analysis of data collected in a cross-sectional study conducted in 2014 in Spain was performed. Health professionals from hospitals and primary care completed an online survey. RESULTS: The responses from 1087 front-line healthcare professionals were analyzed. The willingness of the professionals to fully disclose an AAE was greater among those who were backed by their institution (odds ratio [OR] = 72.6, 95% confidence interval [CI] = 37.5-140.3) and who had experience with that type of communication (OR = 2.4, 95% CI = 1.3-4.5). An apology for the patient was more likely when there was institutional support (OR = 31.3, 95% CI = 14.4-68.2), the professional was not aware of lawsuits (OR = 2.7, 95% CI = 1.2-6.1), and attributed most AAE to human error (OR = 2.2, 95% CI = 1.1-4.2). The fear of lawsuits was determined by the lack of support from the center in disclosing AAE (OR = 5.5, 95% CI = 2.8-10.6) and the belief that being open would result in negative consequences (OR = 2.0, 95% CI = 1.1-3.6). CONCLUSIONS: The culture of safety, the experience of blame, and the expectations about the outcome from communicating an AAE to patients affect the frequency of open disclosure. Nurses are more willing than physicians to participate in open disclosure. Health care organizations must act to establish a framework of legal certainty for professionals.

Histiocytic hyperplasia with hemophagocytosis and acute alveolar damage in COVID-19 infection.

The spectrum of COVID-19 infection includes acute respiratory distress syndrome (ARDS) and macrophage activation syndrome (MAS), although the histological basis for these disorders has not been thoroughly explored. Post-mortem pulmonary and bone marrow biopsies were performed in 33 patients. Samples were studied with a combination of morphological and immunohistochemical techniques. Bone marrow studies were also performed in three living patients. Bone marrow post-mortem studies showed striking lesions of histiocytic hyperplasia with hemophagocytosis (HHH) in most (16/17) cases. This was also observed in three alive patients, where it mimicked the changes observed in hemophagocytic histiocytosis. Pulmonary changes included a combination of diffuse alveolar damage with fibrinous microthrombi predominantly involving small vessels, in particular the alveolar capillary. These findings were associated with the analytical and clinical symptoms, which helps us understand the respiratory insufficiency and reveal the histological substrate for the macrophage activation syndrome-like exhibited by these patients. Our results confirm that COVID-19 infection triggers a systemic immune-inflammatory disease and allow specific therapies to be proposed.

Evaluating standards of care in psoriatic arthritis of the QUANTUM project (qualitative initiative to improve outcomes): results of an accreditation project in Spain.

In Spain, the QUANTUM project has been promoted to reduce variability in clinical practice and improve the care and quality of life of people with psoriatic arthritis (PsA) by accrediting PsA units throughout the Spanish national health system. To present the results of this approach which sought to ensure an optimum level of quality for patients with PsA. Descriptive analysis of the self-assessments that the PsA units have carried out assessing their degree of compliance with the quality standards established in the QUANTUM project grouped into four blocks: shortening time to diagnosis; optimizing disease management; improving multidisciplinary collaboration; and improving patient monitoring. A total of 41 PsA units were self-evaluated. They met 64.1% of the defined quality standards. Optimize disease management obtained a higher level of standards compliance (72%) and improve multidisciplinary collaboration the lesser (63.9%). Accessibility to the treatments available for PsA in all hospitals was guaranteed (100%). Appropriate diagnostic equipment is available (97.6%). Compliance with specific quality standards leads to detect actions that should be implemented: quality of life assessment (9.8%), locomotor system assessment (12.2%), physical examination data record (14.6%), periodic cardiovascular risk assessment (17.1%). The QUANTUM project results make it possible to visualise how to care for patients with PsA is being developed in Spain. Problems identified in recent multinational reports are also identified in Spain.

Low-Value Clinical Practices: Knowledge and Beliefs of Spanish Surgeons and Anesthetists.

OBJECTIVES: To know the frequency and causes of low value surgical practices, according to the opinion of surgeons and anesthetists, and to determine their degree of knowledge about the Spanish "Choosing wisely" initiative. METHODS: Cross-sectional observational study, based on a self-administered online questionnaire through an opportunistic sample of 370 surgeons and anesthetists from three Spanish regions, contacted through Scientific Societies. The survey took part between July and December 2017. RESULTS: A patient profile requesting unnecessary practices was identified (female, 51-65 years old and unaffiliated disease). The frequency of requests was weekly or daily for 50.0% of the professionals, of whom 15.1% acknowledged succumbing to these pressures. To dissuade the patient, clinical reasons (47%) were considered the most effective. To increase control and safety in the case was the main reason to indicate them. The greatest responsibility for overuse was attributed to physicians, defensive medicine and mass media. Assessing professionals' knowledge on unnecessary practices, an average of 5 correct answers out of 7 was obtained. Some 64.1% of the respondents were unaware of the Spanish "Choosing wisely" initiative. CONCLUSIONS: Low value surgical practices are perceived as a frequent problem, which requires an approach entailing intervention with patients and the media as well as professionals. Increase awareness on unnecessary surgical practices, and how to avoid them remain essential.

What Ibero-American hospitals do when things go wrong? A cross-sectional international study.

OBJECTIVE: To know what hospital managers and safety leaders in Ibero-American countries are doing to respond effectively to the occurrence of adverse events (AEs) with serious consequences for patients. DESIGN: Cross-sectional international study. SETTING: Public and private hospitals in Ibero-American countries (Argentina, Brazil, Chile, Colombia, Mexico, Peru, Portugal and Spain). PARTICIPANTS: A convenience sample of hospital managers and safety leaders from eight Ibero-American countries. A minimum of 25 managers/leaders from each country were surveyed. INTERVENTIONS: A selection of 37 actions for the effective management of AEs was explored. These were related to the safety culture, existence of a crisis plan, communication and transparency processes with the patients and their families, attention to second victims and institutional communication. MAIN OUTCOME MEASURE: Degree of implementation of the actions studied. RESULTS: A total of 190 managers/leaders from 126 (66.3%) public hospitals and 64 (33.7%) private hospitals participated. Reporting systems, in-depth analysis of incidents and non-punitive approaches were the most implemented interventions, while patient information and care for second victims after an AE were the least frequent interventions. CONCLUSIONS: The majority of these hospitals have not protocolized how to act after an AE. For this reason, it is urgent to develop and apply a strategic action plan to respond to this imperative safety challenge. This is the first study to identify areas of work and future research questions in Ibero-American countries.

SOBRINA Spanish study-analysing the frequency, cost and adverse events associated with overuse in primary care: protocol for a retrospective cohort study.

INTRODUCTION: Several institutions and quality national agencies have fostered the creation of recommendations on what not to do to reduce overuse in clinical practice. In primary care, their impact has hardly been studied. The frequency of adverse events (AEs) associated with doing what must not be done has not been analysed, either. The aim of this study is to measure the frequency of overuse and AEs associated with doing what must not be done (commission errors) in primary care and their cost. METHODS AND ANALYSIS: A coordinated, multicentric, national project. A retrospective cohort study using computerised databases of primary care medical records from national agencies and regional health services will be conducted to analyse the frequency of the overuse due to ignore the do-not-do recommendations, and immediately afterwards, depending on their frequency, a representative random sample of medical records will be reviewed with algorithms (triggers) that determine the frequency of AEs associated with these recommendations. Cost will determine by summation of the direct costs due to the consultation, pharmacy, laboratory and imaging activities according to the cases. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Committee of Primary Care Research of the Valencian Community. We aim to disseminate the findings through international peer-reviewed journals and on the website (http://www.nohacer.es/). Outcomes will be used to incorporate algorithms into the electronic history to assist in making clinical decisions. TRIAL REGISTRATION NUMBER: NCT03482232; Pre-results.

Low-value clinical practices and harm caused by non-adherence to 'do not do' recommendations in primary care in Spain: a Delphi study.

OBJECTIVE: To determine the non-adherence to the primary care 'do not do' recommendations (DNDs) and their likelihood to cause harm. DESIGN: Delphi study. SETTING: Spanish National Health System. PARTICIPANTS: A total of 128 professionals were recruited (50 general practitioners [GPs], 28 pediatricians [PEDs], 31 nurses who care for adult patients [RNs] and 19 pediatric nurses [PNs]). INTERVENTIONS: A selection of 27 DNDs directed at GPs, 8 at PEDs, 9 at RNs and 4 at PNs were included in the Delphi technique. A 10-point scale was used to assess whether a given practice was still present and the likelihood of it causing of an adverse event. MAIN OUTCOME MEASURE: Impact calculated by multiplying an event's frequency and likelihood to cause harm. RESULTS: A total of 100 professionals responded to wave 1 (78% response rate) and 97 of them to wave 2 (97% response rate). In all, 22% (6/27) of the practices for GPs, 12% (1/8) for PEDs, 33% (3/9) for RNs and none for PNs were cataloged as frequent. A total of 37% (10/27) of these practices for GPs, 25% (2/8) for PEDs, 33% (3/9) for RNs and 25% (1/4) for PNs were considered as potential causes of harm. Only 26% (7/27) of the DNDs for GPs showed scores equal to or higher than 36 points. The impact measure was higher for ordering benzodiazepines to treat insomnia, agitation or delirium in elderly patients (mean = 57.8, SD = 25.3). CONCLUSIONS: Low-value and potentially dangerous practices were identified; avoiding these could improve care quality.

Drivers and strategies for avoiding overuse. A cross-sectional study to explore the experience of Spanish primary care providers handling uncertainty and patients' requests.

OBJECTIVES: Identify the sources of overuse from the point of view of the Spanish primary care professionals, and analyse the frequency of overuse due to pressure from patients in addition to the responses when professionals face these demands. DESIGN: A cross-sectional study. SETTING: Primary care in Spain. PARTICIPANTS: A non-randomised sample of 2201 providers (general practitioners, paediatricians and nurses) was recruited during the survey. PRIMARY AND SECONDARY OUTCOME MEASURES: The frequency, causes and responsibility for overuse, the frequency that patients demand unnecessary tests or procedures, the profile of the most demanding patients, and arguments for dissuading the patient. RESULTS: In all, 936 general practitioners, 682 paediatricians and 286 nurses replied (response rate 18.6%). Patient requests (67%) and defensive medicine (40%) were the most cited causes of overuse. Five hundred and twenty-two (27%) received requests from their patients almost every day for unnecessary tests or procedures, and 132 (7%) recognised granting the requests. The lack of time in consultation, and information about new medical advances and treatments that patients could find on printed and digital media, contributed to the professional's inability to adequately counter this pressure by patients. Clinical safety (49.9%) and evidence (39.4%) were the arguments that dissuaded patients from their requests the most. Cost savings was not a convincing argument (6.8%), above all for paediatricians (4.3%). General practitioners resisted more pressure from their patients (x2=88.8, P<0.001, percentage difference (PD)=17.0), while nurses admitted to carrying out more unnecessary procedures (x2=175.7, P<0.001, PD=12.3). CONCLUSION: Satisfying the patient and patient uncertainty about what should be done and defensive medicine practices explains some of the frequent causes of overuse. Safety arguments are useful to dissuade patients from their requests.

Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations.

PURPOSE: To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present. DATA SOURCES: Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety. STUDY SELECTION: Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals. DATA EXTRACTION: Study characteristic and outcome data were abstracted by two authors and reviewed by the research team. RESULTS OF DATA SYNTHESIS: Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization. CONCLUSION: Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.

The Second Victim Phenomenon After a Clinical Error: The Design and Evaluation of a Website to Reduce Caregivers' Emotional Responses After a Clinical Error.

BACKGROUND: Adverse events (incidents that harm a patient) can also produce emotional hardship for the professionals involved (second victims). Although a few international pioneering programs exist that aim to facilitate the recovery of the second victim, there are no known initiatives that aim to raise awareness in the professional community about this issue and prevent the situation from worsening. OBJECTIVE: The aim of this study was to design and evaluate an online program directed at frontline hospital and primary care health professionals that raises awareness and provides information about the second victim phenomenon. METHODS: The design of the Mitigating Impact in Second Victims (MISE) online program was based on a literature review, and its contents were selected by a group of 15 experts on patient safety with experience in both clinical and academic settings. The website hosting MISE was subjected to an accreditation process by an external quality agency that specializes in evaluating health websites. The MISE structure and content were evaluated by 26 patient safety managers at hospitals and within primary care in addition to 266 frontline health care professionals who followed the program, taking into account its comprehension, usefulness of the information, and general adequacy. Finally, the amount of knowledge gained from the program was assessed with three objective measures (pre- and posttest design). RESULTS: The website earned Advanced Accreditation for health websites after fulfilling required standards. The comprehension and practical value of the MISE content were positively assessed by 88% (23/26) and 92% (24/26) of patient safety managers, respectively. MISE was positively evaluated by health care professionals, who awarded it 8.8 points out of a maximum 10. Users who finished MISE improved their knowledge on patient safety terminology, prevalence and impact of adverse events and clinical errors, second victim support models, and recommended actions following a severe adverse event (P<.001). CONCLUSIONS: The MISE program differs from existing intervention initiatives by its preventive nature in relation to the second victim phenomenon. Its online nature makes it an easily accessible tool for the professional community. This program has shown to increase user's knowledge on this issue and it helps them correct their approach. Furthermore, it is one of the first initiatives to attempt to bring the second victim phenomenon closer to primary care.

[What are hospitals and primary care doing to mitigate the social impact of serious adverse events]. / Qué hacen los hospitales y la atención primaria para mitigar el impacto social de los eventos adversos graves.

OBJECTIVE: To explore what hospitals and primary care (PC) are doing to reduce the negative social impact of a serious adverse event (AE). METHODS: We surveyed 195 hospital (n=113) and PC (n=82) managers from eight autonomous communities to explore the level of implementation of five interventions recommended after an AE to protect the reputation of healthcare institutions. RESULTS: Most institutions (70, 45.2% PC, and 85, 54.8% hospitals) did not have a crisis plan to protect their reputation after an AE. Internal (p=0.0001) and external (p=0.012) communications were addressed better in PC than in hospitals. Very few institutions had defined the managers' role in case of an AE (10.7% hospitals versus 6.25% PC). CONCLUSION: A majority of healthcare institutions have not planned crisis intervention after an AE with severe consequences nor have they defined plans to recover citizens' trust after an AE.

Interventions in health organisations to reduce the impact of adverse events in second and third victims.

BACKGROUND: Adverse events (AE) are also the cause of suffering in health professionals involved. This study was designed to identify and analyse organization-level strategies adopted in both primary care and hospitals in Spain to address the impact of serious AE on second and third victims. METHODS: A cross-sectional study was conducted in healthcare organizations assessing: safety culture; health organization crisis management plans for serious AE; actions planned to ensure transparency in communication with patients (and relatives) who experience an AE; support for second victims; and protective measures to safeguard the institution's reputation (the third victim). RESULTS: A total of 406 managers and patient safety coordinators replied to the survey. Deficient provision of support for second victims was acknowledged by 71 and 61% of the participants from hospitals and primary care respectively; these respondents reported there was no support protocol for second victims in place in their organizations. Regarding third victim initiatives, 35% of hospital and 43% of primary care professionals indicated no crisis management plan for serious AE existed in their organization, and in the case of primary care, there was no crisis committee in 34% of cases. The degree of implementation of second and third victim support interventions was perceived to be greater in hospitals (mean 14.1, SD 3.5) than in primary care (mean 11.8, SD 3.1) (p < 0.001). CONCLUSIONS: Many Spanish health organizations do not have a second and third victim support or a crisis management plan in place to respond to serious AEs.

Dermatofibrosarcoma Protuberans of the Vulva With Myoid Differentiation.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor characterized by a relatively high risk for local recurrence and low risk for metastasis. Many histopathologic variants of DFSP have been described, including the fibrosarcomatous and myoid variants, which may obscure the diagnosis in some cases, especially when arising in unusual locations. Of all the variants described so far, the only one with prognostic relevance is the FS-DFSP variant, which implies tumor progression and a higher possibility for metastasis. The authors report a case of a giant DFSP, located on the vulvar area, which histopathologically showed areas of fibrosarcomatous and myoid differentiation, and discuss the importance of the myoid variant in regards of the debated histogenesis of DFSP.

The aftermath of adverse events in Spanish primary care and hospital health professionals.

BACKGROUND: Adverse events (AEs) cause harm in patients and disturbance for the professionals involved in the event (second victims). This study assessed the impact of AEs in primary care (PC) and hospitals in Spain on second victims. METHODS: A cross-sectional study was conducted. We carried out a survey based on a random sample of doctors and nurses from PC and hospital settings in Spain. A total of 1087 health professionals responded, 610 from PC and 477 from hospitals. RESULTS: A total of 430 health professionals (39.6%) had informed a patient of an error. Reporting to patients was carried out by those with the strongest safety culture (Odds Ratio -OR- 1.1, 95% Confidence Interval -CI- 1.0-1.2), nurses (OR 1.9, 95% CI 1.5-2.3), those under 50 years of age (OR 0.7, 95% CI 0.6-0.9) and primary care staff (OR 0.6, 95% CI 0.5-0.9). A total of 381 (62.5%, 95% CI 59-66%) and 346 (72.5%, IC95% 69-77%) primary care and hospital health professionals, respectively, reported having gone through the second-victim experience, either directly or through a colleague, in the previous 5 years. The emotional responses were: feelings of guilt (521, 58.8%), anxiety (426, 49.6%), re-living the event (360, 42.2%), tiredness (341, 39.4%), insomnia (317, 38.0%) and persistent feelings of insecurity (284, 32.8%). In doctors, the most common responses were: feelings of guilt (OR 0.7 IC95% 0.6-0.8), re-living the event (OR 0.7, IC95% o.6-0.8), and anxiety (OR 0.8, IC95% 0.6-0.9), while nurses showed greater solidarity in terms of supporting the second victim, in both PC (p = 0.019) and hospital (p = 0.019) settings. CONCLUSIONS: Adverse events cause guilt, anxiety, and loss of confidence in health professionals. Most are involved in such events as second victims at least once in their careers. They rarely receive any training or education on coping strategies for this phenomenon.

Effects of diazepam on fentanyl-induced epileptoid EGG activity and increase of multineuronal firing in limbic and mesencephalic brain structures

Electroencephalographic and clinical signs of epileptoid activity have been associated with the administration offentanyl during surgery in patients. These phenomena have been in turn related to changes in metabolic rate, oxygen consumption, and blood flow in specific brain structures both in humans and experimental animals. However, direct evidence showing changes in neuronal firing in specific brain regions during fentanyl-induced epileptoid activity has not been reported. Eight adult male cats with chronically implanted bipolar electrodes in the mesencephalic reticular formation, hippocampus, amygdala, and parieto-occipital cortex were included in the study. Different treatments i.e., vehicle-fentanyl or diazepam-fentanyl, were administered to the experimental animals at 7-day intervals under neuromuscular blockade and assisted ventilation. Electroencephalographic (EEG) seizures, grouped and isolated spikes, and significant increases of multineuronal activity (MUA) were elicited by fentanyl, 50 µg/kg iv, in these brain structures. Both EEG and MUA changes reached their maximal values within 6 min of fentanyl administration, and then diminished as time elapsed. Diazepam, 100, 200, or 400 µg/kg, but not 50 µg/kg iv, significantly reduced or prevented the fentanyl-induced epileptoid EEG activity and MUA increases. The present results show that both entanyl- induced epileptoid EEGactivity as wel as the concomitant increase in MUA of brain subcortical structures are part of the same epileptogenic phenomenon, mainly generated at limbic structures. In addition, the effects of fiazepamagainst both epileptoid EEG activity and increase of MUA of brain subcortical structures support the use of benzodiazepine as premedicants for fentanyl anesthesia in order to prevent or to reduce epileptoid phenomena that can results from opioid administration during the anesthetic procedures