Catastrophic Medical Malpractice Payouts in Spain.

Patient safety and professional liability are major concerns worldwide. Despite the pervasive influence of catastrophic malpractice payouts, little is known about the specific characteristics and the overall relevance and characteristics of these payouts, especially outside U.S. borders. Five hundred fifty claims led to a payout among 2,236 claims from January 1, 2004 to December 31, 2010, in Catalonia (Spain). We analyzed data on patient, provider, and claim characteristics. Accordingly to our sample, Spanish catastrophic payouts (SCP) were defined as payouts over &OV0556;200,000, which was found in 32 cases (5.8%). Diagnostic errors and patient death were not as relevant as previously reported. However, it is remarkable that the literature emanating from different countries shows similar trends besides contextual differences: patients suffering minor injuries are not likely to receive a catastrophic payout, catastrophic payouts are associated with patient age less than one; SCP are most associated with anesthesiology and resuscitation, general surgery, and obstetrics and gynecology; and SCP were more likely to occur when a case went to trial compared to when a case was settled out of court. Studies, such as this, provide a wider picture of the medical liability worldwide reality and helps avoiding isolated discourses.

A study of the cost, accuracy, and benefits of 3-dimensional sonography compared with hysterosalpingography in women with uterine abnormalities.

OBJECTIVES: We conducted a prospective blinded study to evaluate the costs, accuracy, risks, and benefits of 3-dimensional (3D) transvaginal sonography compared to hysterosalpingography. METHODS: A total of 101 women aged 26 to 44 years with evidence of uterine anomalies were enrolled. All participants had routine hysterosalpingography as part of their infertility evaluation as well as 3D transvaginal sonography as part of the study. Surgical findings were used as the standard for final diagnosis. RESULTS: A total of 6 normal uteri and 119 uterine anomalies were classified: 30 congenital uterine anomalies (3 arcuate, 1 unicornuate, 4 bicornuate, 2 didelphys, and 20 septate uteri) and 89 acquired anomalies (38 polyps, 30 fibroids, 17 synechiae, and 4 adenomyosis). Congenital anomalies were correctly identified in 30 of 30 cases by 3D sonography but from 10 to 30 of 30 cases by hysterosalpingography. The detection rates for acquired uterine anomalies were lower for both techniques: 44 to 89 of 89 cases for 3D sonography and 22 to 74 of 89 cases for hysterosalpingography. Only 7 of the 20 septi would have been surgically corrected if patients only had hysterosalpingography. On the contrary, 30 of 30 patients with congenital uterine anomalies, 2 of 4 patients with adenomyosis, and all 6 patients with normal uteri were spared from surgery with diagnoses by 3D sonography. No adverse effects were reported after sonography, and only 6 minor ones were reported after hysterosalpingography. CONCLUSIONS: Three-dimensional transvaginal sonography provides visualization and evaluation of the uterine cavity with similar or better accuracy than standard hysterosalpingography in the office setting, with lower cost and morbidity.

Assessment of ovarian reserve with anti-Müllerian hormone: a comparison of the predictive value of anti-Müllerian hormone, follicle-stimulating hormone, inhibin B, and age.

OBJECTIVE: The objective of this study was to evaluate basal anti-Müllerian hormone as a marker for ovarian responsiveness to fertility treatment. STUDY DESIGN: Frozen basal menstrual cycle day 3 serum samples were evaluated retrospectively for anti-Müllerian hormone, inhibin B, and follicle-stimulating hormone levels in 123 in vitro fertilization cycles (93 patients) and compared with in vitro fertilization records. RESULTS: Anti-Müllerian hormone values correlated the best with the number of retrieved oocytes (r = 0.539; P < .001) relative to age (r = -0.323; P < .01), follicle-stimulating hormone (r = -0.317; P < .01), inhibin B (P > .05), luteinizing hormone (P > .05), and estradiol (r = -0.190; P < .05). Receiver operating characteristic curve analysis demonstrated that, for the prediction of <4 oocytes retrieved, anti-Müllerian hormone had the largest area under the curve (AUC = 0.81; P = .0001) relative to age (r = 0.74; P = .005), follicle-stimulating hormone (0.71; P = .02), inhibin B (0.66; P = .03), and estradiol (0.54; P > .05). Similarly, for the prediction of >or=15 retrieved oocytes, anti-Müllerian hormone had the largest area under the curve (0.80; P = .0001) relative to age (0.63; P = .02), follicle-stimulating hormone (0.64; P = .005), inhibin B (r = 0.57; P > .05), and estradiol (0.58; P > .05). CONCLUSION: Anti-Müllerian hormone correlates better than age, follicle-stimulating hormone, luteinizing hormone, inhibin B, and estradiol with the number of retrieved oocytes. Receiver operating characteristic curves estimated that anti-Müllerian hormone accurately predicts ovarian responsiveness to controlled ovarian stimulation with high sensitivity and specificity.

The assessment of internal mammary artery grafts by colour Doppler in coronary artery surgery.

BACKGROUND: Various studies in progress on the flow and diameter parameters based assessment and suitability of internal mammary artery by preoperative colour Doppler examination in coronary artery surgery. Postoperative visualisation of these grafts is also in evolution. Due to its noninvasive approach, colour Doppler sonography is taking its place in the follow-up of coronary artery bypass procedure. The aim of this study was to show the effectiveness and feasibility of colour Doppler in the routine postoperative follow-up evaluation. METHODS: In GATA Haydarpasa Education Hospital, coronary artery bypass grafting was performed by anastomosing left internal mammary artery to left anterior descending artery and saphenous veins to remaining lesions of the coronary arteries in 36 male patients between the ages of 42 to 66 (mean 54.8) in 1995. Left internal mammary artery and unused right internal mammary artery were imaged by colour Doppler six to eight weeks after the operations in all cases. Coronary angiography was also performed in two cases 4 months postoperatively. RESULTS: Colour Doppler sonography findings showed that the diameter of left internal mammary artery was larger (p=0.03) and mean flow value was greater than intact right internal mammary artery (p=0.02). CONCLUSIONS: These results shows that colour Doppler sonography should be applied as a noninvasive method, in the follow-up of internal mammary artery grafts after coronary artery revascularisation.

[Bases for formulating a program to promote breast-feeding: methodological aspects].

Based on the relevance of breastfeeding for maternal-infant health, it is necessary that the prospective and longitudinal studies carried out in Mexico be analyzed as a whole in order to create an analytic model and to develop an institutional intervention program concerning the mother's risk of not starting or of abandoning lactation. To create this program all the factors which can be modified must be taken into account in order to make sure the mother has the elements to make a decision. The National Institute of Perinatology has developed a research program about lactation that consists of 3 studies that have been carried out since 1983. The general aim of these studies is to understand the breastfeeding phenomenon in an integral way considering the role of the institution as an educational instrument and a means of providing health support. These studies were based on different perspectives, approaches and times but had similar objectives. For this reason it is desirable to analyze them as a whole in order to obtain new considerations and temporal projections. In order to integrate the 3 studies a database will be created and then an analytical model (from a multivariate analysis) will be generated from the 1st study (by temporal order) which will be tested in the 2nd study making the pertinent modifications and finally it will be applied in the 3rd study. At the same time it will be necessary to group the variables into 2 classification systems: The first according to the temporal proximity with regard to lactation and the second according to the organization level to which they belong.

[Exploration of factors which could modify the establishment and duration of breastfeeding]. / Exploracion de factores que pueden modificar el establecimiento y la duracion de la lactancia

PIP: Interest in the present study grew out of the concern for the large number of women who have suffered a perinatal loss at the Instituto Nacional de Perinatologia, a high-risk pregnancy hospital in Mexico. The purpose of the study was to offer high quality psychological treatment while at the same time including a large number of patients. A psychoanalytically-oriented open group was formed for those patients identified as having problems in resolving the mourning process. A total of 15 patients were seen on a weekly basis for 33 sessions of 1 1/2 hours duration each. An average of 5 patients attended each session. The data consist of clinical notes and impressions for each group session, which were divided into 4 stages according to the group progress. The course of resolution of grief of a group of patients with perinatal loss was found to correspond closely to the stages of mourning noted frequently in the clinical literature for individual patients. Suggestions are offered for management of the obstetric patient with perinatal loss. (author's modified)^ieng

Growth pattern of selected urban Chilean infants during exclusive breast-feeding.

This report describes the growth pattern of healthy, low middle and low socioeconomic class Chilean infants during exclusive breast-feeding. Two-hundred forty-two infants who were on exclusive breast-feeding at day 30 postpartum entered the study. Of these, 59% were fully nursing at 6 months and grew at a normal rate without receiving either supplementary milk or nondairy food. Supplementary feedings were administered in 27% of cases because of suspected primary inadequate milk output and in 14% of cases for other reasons such as pregnancy, illness, maternal work, or self-prescription. Full nursing provided the highest rate of weight increase during the first 3 months of life and a greater weight gain for boys than for girls up to the age of 6 months. Gastrointestinal pathology, malnourishment, or hospitalization were rare events in this population. It is concluded that maternal milk alone, if produced in sufficient amounts, can maintain normal growth up to the 6th month of life. The study supports the choice of exclusive breast-feeding on demand plus child growth monitoring up to 6 months over routine prescription of supplements at earlier times particularly where supplement administration fails to meet individual requirements.

PIP: This report describes the growth pattern of healthy, low middle and low socioeconomic class Chilean infants during exclusive breastfeeding. 242 infants who were on exclusive breastfeeding at day 30 postpartum entered the study. Of these, 59% were fully nursing at 6 months and grew at a normal rate without receiving either supplementary milk or nondairy food. Supplementary feedings were administered in 27% of the cases because of suspected primary inadequate milk output and in 14% of cases for other reasons such as pregnancy, illness, maternal work, or self prescription. Full nursing provided the highest rate of weight increase during the 1st 3 months of life and greater weight gain for boys than for girls up to the age of 6 months. Gastrointestinal pathology, malnourishment, or hospitalization were rare events in this population. It is concluded that maternal milk alone, if produced in sufficient amounts, can maintain normal growth up to the 6th month of life. The study supports the choice of exclusive breast feeding on demand plus child growth monitoring up to 6 months over routine prescription of supplements at earlier times particularly where supplement administration fails to meet individual requirements.

Fertility regulation in nursing women. II. Comparative performance of progesterone implants versus placebo and copper T.

A clinical study was designed to test whether sustained administration of progesterone to nursing mothers could prolong lactation and delay the postpartum recovery of fertility. The hormone was administered by subdermal implantation of six pellets that each contained 100 mg of progesterone. This treatment was administered to 84 fully nursing women on day 30 post partum. Control groups were composed of 130 fully nursing women who received an injectably placebo, and by 125 fully nursing women who received a TCu 200 intrauterine contraceptive device. An exacting list of requirements for admission to and continuation in the study was applied to all groups. No pregnancies occurred in the progesterone-treated group from the second to the sixth postpartum month. This period coincided with the period of elevation plasma progesterone attributable to hormone released from the implants. The cumulative probability of pregnancy in the placebo group was 10.2 per 100 women at the sixth month. Treatment with progesterone did not change the duration of lactation or the rate of child growth, and no adverse effects were recorded. These results warrant further investagation of the use of progesterone as an alternative method to prevent conception in nursing women.

PIP: A clinical study was conducted to test whether sustained administration of progesterone to nursing mothers could prolong lactation and delay the postpartum recovery of fertility. Study participants were living in the Central Area of Santiago, Chile at the time of delivery. The hormone was administered by subdermal implantation of 6 pellets that each contained 100 mg of progesterone. This treatment was administered to 84 fully nursing women on day 30 postpartum. Control groups were composed of 130 fully nursing women who received an injectable placebo, and by 125 fully nursing women who received a TCu 200 IUD. An exacting list of requirements for admission to and continuation in the study was applied to all groups. No pregnancies occurred in the progesterone treated group from the 2nd to the 6th postpartum month. This period coincided with the period of elevated plasma progesterone attributable to hormmone released from the implants. The cumulative probability of pregnancy in the placebo group was 10.2/100 women at the 6th month. Pregnancy was the most frequent reason for termination from the 7th month to the 12th postpartum months in the progesterone and the placebo groups, both of which had a higher number of terminations than the copper T group. The proportion of women in full nursing ranged from 51.2 to 58.3 at the 6th postpartum month and from 10.7 to 17.6 at the end of the year. At the 12th month the IUD group had the highest percentage of women in full nursing and the lowest percentage of terminations. In regard to child growth, there were no significant differences between the 3 groups at any month when the averages were analyzed by Student's t test. In sum, treatment with progesterone did not change the duration of lactation or the rate of child growth. No adverse effects were recorded. Bleeding patterns were similar in the 3 groups. The local tolerance to pellets was good, and no clinical or laboratory side effects were detected. Results obtained with progesterone pellets are encouraging. Further study is needed to confirm their efficacy and acceptability.