Chile: reaping the rewards of investments in quality.

PIP: During the first 2 years of a quality assurance program/Ministry of Health collaboration in Chile, training, organization, and planning were emphasized. During the third year, a significant number of small teams were achieving quality improvements at the local level. Currently, 50 projects on different aspects of maternal and child health care are in various stages of completion, covering between 1 and 10 health centers each. In Santiago, health center staff improved breast feeding support and achieved 60% exclusive breast feeding at 4 months (33% at 6 months) as well as an improvement in health professionals' knowledge from 4.25 to 6.43 on a scale of 1 to 7. A regional effort undertaken by a group of midwives improved the collection, dissemination, and analysis of information about the incidence of low birth weight infants so that this information could provide the high-quality data necessary to influence planning and programming decisions. In Santiago, which has the highest rate of adolescent pregnancies in Chile, a midwives group improved the way in which information on prenatal care was given to these young women during their prenatal orientation. By including all of the relevant information on one card, the midwives improved significantly the likelihood that the adolescents would make and keep the necessary appointments and that they would have important information at their fingertips. The teens all saved the cards as keepsakes of their first pregnancies. Also in Santiago, a team of physicians assessed the quality of care in treating acute respiratory infections. They found that over 80% of providers did not have time to record the necessary information which would insure appropriate care as the patient moved through the health system. An initial effort to improve this situation was only partially successful, so the physicians are developing a more detailed plan. In the final example, a physician evaluated the quality of record-keeping across 7 specialties in his hospital and found it lacking. The initial response to the findings was not positive, but as providers received more training in quality evaluation and improvement, attitudes changed. The hospital formed a medical records committee to develop ways to improve record-keeping and, thus, patient care. This indicates that a move from evaluation to improvement requires broad-based awareness of the merits of quality control.^ieng

[Doppler echocardiographic evaluation of functional parameters of mechanical and biological valve prostheses]. / Valutazione tramite ecocardiografia-Doppler dei parametri funzionali di protesi valvolari meccaniche e biologiche.

We studied and compared functional parameters in 314 valvular prostheses. The following parameters have been calculated: mean transvalvular gradients for aortic and mitral prostheses and functional area by Pht (pressure half time) for mitral prostheses. All patients with important depression in myocardial function, tachycardia or malfunctioning prostheses were excluded. 173 prostheses were in aortic position and 141 in mitral position. Mitral prostheses were: 31 biological and 110 mechanical. We subdivided mechanical prostheses in monoleaflet (Omnicarbon, Sorin-Carbocast and Allcarbon, Medtronic, Bjork-Shiley) and bileaflet (Sorin-Bicarbon, St. Jude). These three groups were compared: mean transvalvular gradients and area showed no differences. Aortic prostheses were: 33 biological and 140 mechanical; mechanical prostheses were subdivided in two groups: monoleaflet (Sorin Allcarbon e Carbocast, Bjork-Shiley, Medtronic, Omnicarbon) and bileaflet (Sorin-Bicarbon, St. Jude). Mean transvalvular gradients of these three groups were compared within each group for every size: bileaflet prostheses demonstrated inferior gradients than biological and monoleaflet for 19-21 and 23 sizes; in superior sizes there were no significant differences. Further analysis showed a significant correlation among gradients and body surface area in the 21 size prostheses (p = 0.004). Bileaflet prostheses in this subgroup showed less increase in mean gradient with surface area than mechanical and biological ones.

[Serial Doppler echocardiography follow-up studies in the postoperative evaluation of severe pulmonary hypertension following surgery for mitral and mitral-aortic defects]. / Valutazione postoperatoria del comportamento della ipertensione polmonare grave nei vizi mitralici e mitroaortici tramite controlli seriati con ecocardiografia Doppler.

Between January 1987 and December 1991 26 patients with mitral and mitro-aortic disease and severe pulmonary hypertension (> or = 60 mmHg) were subjected to surgery. In 22 patients we have studied systolic pulmonary pressures by echocardiography-Doppler examination at 3-6 and 12 months from surgery. We noticed a decrease in pulmonary pressure values in all patients within 3 months from surgery (mean values pre-op 75 +/- 12.14; mean values post-op 42 +/- 11.26); within 6 months from surgery physiological values were reached in all patients (mean values 35 +/- 5.3). We have further divided patients in two subgroups: group A with pulmonary pressures superior or equal to 80 mmHg (mean values 90.00 +/- 17.32) and group B With pressure values between 60 and 79 mmHg (mean values 69.12 +/- 3.64). The first Doppler evaluation demonstrated a greater decrease in group B (mean values 37.8 +/- 6.5 versus 57 +/- 12.4); at the second control there was no statistically significant difference between the two groups (group A 36 +/- 5.48, group B 33.33 +/- 5.37). The only two operative deaths were caused by the pre-op cardiogenic shock. There has been no late mortality among survivors, 22 in NYHA Class I and 2 in NYHA Class II. Pulmonary hypertension decreases after surgery independently of the adopted procedure (replacement, repair or lysis).

Cardiac diastolic abnormalities and atrial natriuretic factor in essential hypertension.

Cardiac function and plasma levels of atrial natriuretic factor (ANF) were studied in a group of 38 patients with untreated essential hypertension and in a group of 31 well matched normotensive controls. ANF was slightly but significantly higher in hypertensives and was directly correlated with mean arterial pressure and inversely with plasma renin activity (PRA). Hypertensives showed normal systolic function and higher cardiac mass compared to controls. ANF was inversely correlated to echocardiographic indexes of left ventricular performance in the former group. At Doppler echocardiographic evaluation, hypertensives showed an impairment in diastolic function which was correlated to the increase in ANF levels. Stepwise multiple regression analysis performed with ANF as the dependent variable and several biohumoral and echocardiographic parameters as the independent variables showed that only cardiac diastolic function and PRA significantly affect ANF levels in hypertensives. In conclusion, an impairment in cardiac diastolic function may be responsible together with other factors for the increased ANF levels encountered in essential hypertension.

[The echocardiographic evaluation of valve prostheses]. / Valutazione ecocardiografica delle protesi valvolari.

Transthoracic and transesophageal echocardiography were used to demonstrate prosthetic valve dysfunction in 134 patients with cardiac prosthetic valves in aortic, mitral and tricuspid position. Transthoracic echocardiography showed a high accuracy in the diagnosis of prosthetic valve dysfunction, especially in aortic position or when a stenosis was present. Transesophageal echocardiography allowed to verify the etiology and site of dysfunction and to show even minor leaks. Sixty-six patients underwent reoperation while 68 underwent a clinical and echocardiographic follow-up because only mild symptoms were present. Thus echocardiography represents the technique of choice in the follow-up of patients with prosthetic valves and it is able to help in decision making. However, cardiac catheterization is mandatory if a disagreement between clinical and echocardiographic data is present or when coronary artery disease is suspected or present.

[The usefulness of echocardiography in the diagnosis of prosthetic valve endocarditis: a comparison between the transthoracic and transesophageal approaches]. / Utilità dell'ecocardiografia nella diagnosi di endocardite su protesi valvolare: confronto tra approccio transtoracico e transesofageo.

Transesophageal echocardiography is a new semi-invasive procedure whose practical application has yet to be precisely defined. The diagnosis of prosthetic valve endocarditis is particularly difficult with the transthoracic approach, either by thoracic conformation of patients who underwent cardiac surgery, or ultrasound attenuation caused by the prosthetic material. Transesophageal echocardiography is useful to overcome such limits with a new acoustic window, due to the proximity of the esophagus and the heart. During 15 months 18 patients with suspected prosthetic valve endocarditis were studied using both procedures. In patients with mitral prosthetic valves, transesophageal echocardiography provided information unobtainable by using the transthoracic procedure, while in patients with aortic prosthetic valves it only showed additional information in 1 case of abscess of the posterior valve ring. In conclusion, transesophageal echocardiography is useful to diagnose all patients with suspected prosthetic mitral valve endocarditis and might be performed in patients with aortic valve prostheses if the quality of the transthoracic procedure is poor.

[Role of transesophageal echocardiography in the diagnosis of diseases of the thoracic aorta]. / Ruolo dell'ecocardiografia transesofagea nella diagnosi di patologie dell'aorta toracica.

The most frequent diseases of thoracic aorta in the adult population, aneurysms and dissection, can lead to dramatic complications. Therefore in these cases an early and careful diagnosis is required for a correct therapeutic choice. The close distance of the thoracic aorta to the esophagus allows a better visualization by transesophageal echocardiography (TEE) compared with the transthoracic approach (TTE). Aim of this study is to evaluate the diagnostic accuracy of TEE versus surgical data in patients with suspected aneurysms and/or dissection of the thoracic aorta. Eighteen patients with aortic aneurysm, confirmed at surgery, underwent B-mode, pulsed Doppler and color echocardiographic examination either by TTE or by TEE. TEE was concordant with surgical findings in all the cases of fusiform (8 patients) and saccular (2 patients) aneurysms, visualizing aortic wall thrombosis in 4 patients. Furthermore TEE, diagnosed all the type I (4 patients) and type III (2 patients) dissection, and 1 type II, identifying in all cases the intimal tear and, in 3 patients, the false lumen thrombosis; it demonstrated the presence of severe aortic regurgitation in 3 patients and of mild pericardial effusion in 2 patients. Only in 1 case of type II dissection TEE was not diagnostic because it is not able to visualize completely the aortic arch. In our experience TEE allowed accurate information in patients with aortic aneurysm or dissection. TEE can be considered the first choice diagnostic tool in patients with suspected dissection of the thoracic aorta.

[Echocardiographic findings in interatrial septal aneurysm, Chiari's network and tricuspid valve prolapse. An unusual association]. / Riscontro ecocardiografico di aneurisma del setto interatriale, rete di Chiari e prolasso della valvola tricuspide. Una associazione originale.

In this report we discuss the case of a 55-year-old female who underwent echocardiographic and Doppler studies for the presence of systolic murmur at physical examination, in which echocardiography showed the concomitant presence of an atrial septal aneurysm, a Chiari network and a tricuspid valve prolapse, a hypothetic association not previously described. The association of atrial septal aneurysm, tricuspid valve prolapse and Chiari network suggests the possibility of a connective disorder involving fibrous tissue of the heart and a concomitant anomalous development of the valves of the sinus venosus.

[Morphologic and functional evaluation of the left ventricle in patients with acromegaly. An echocardiographic study]. / Valutazione morfologica e funzionale del ventricolo sinistro in pazienti con acromegalia. Studio ecocardiografico.

The aim of our study is to detect morphological and functional aspects of left ventricle with noninvasive M-B-Mode echocardiography in acromegalic patients (pz) with and without high blood pressure. We studied 19 acromegalic pz (group A) and 19 normal pz (group N). All subjects were evaluated for the following parameters: left ventricular mass index (MI); end diastolic volume index (EDVI); end systolic volume index (ESVI); ejection fraction (EF); end systolic stress (ESS). Group A vs group N shows an increase of cardiac mass (p less than 0.01), of EDVI (p less than 0.05) and of ESS (p less than 0.05). We found the asymmetrical septal hypertrophy, considered from other Authors one of the more evident markers of acromegaly, in only one patient. In conclusion, the acromegalic pz show an increase of cardiac mass and preload and a reduced capacity of adaptation to afterload variation independently of blood pressure values and of the duration of disease, even if they have normal indexes of global systolic function.