[Medication errors in a neonatal unit: One of the main adverse events]. / Los errores de tratamiento en una unidad neonatal, uno de los principales acontecimientos adversos.

INTRODUCTION: Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. MATERIAL AND METHODS: An analysis was performed on the ME declared in a neonatal unit. RESULTS: A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed. CONCLUSIONS: It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.

Results of induction chemotherapy in children older than 18 months with stage-4 neuroblastoma treated with an adaptive-to-response modified N7 protocol (mN7)

Purpose. We report the response rate in children older than 18 months with stage 4 Neuroblastoma, using a modified dose-intensive, response-adaptive, induction mN7 protocol. Methods. From 2005 to 2012, 24 patients were treated with the mN7 protocol. Phase 1 included five MSKCC N7 cycles and surgery and two high-dose cyclophosphamide-topotecan (HD-CT) cycles for those who did not achieve complete remission (CR) and negative bone marrow (BM) minimal residual disease (MRD) status (CR+MRD-). Phase 2 consisted of myeloablative doses of topotecan, thiotepa and carboplatin plus hyperfractionated RT. Phase 3 included isotretinoin and 3F8 immunotherapy plus GM-CSF. BM MRD was monitored using GD2 synthase, PHOX2B and cyclin D1 mRNAs. Results. After 3 cycles, all patients showed BM complete histological clearance and 6 (25 %) were MRD-. Twenty of 21 s-look surgeries achieved macroscopic complete resection. After 5 cycles and surgery, 123I-MIBG scan was negative in 15 (62.5 %) cases, BM disease by histology was negative in 23 (96 %) and 10 (42 %) patients were MRD-. Twelve (50 %) pts were in CR, 2 in very good partial response (VGPR), 9 partial response (PR) and one had progressive disease. With 2 HD-CT extra cycles, 17 (71 %) pts achieved CR+MRD- status moving to phase 2. Overall and event-free survival at 3 years for the 17 patients who achieved CR+MRD- is 65 and 53 %, respectively, median follow-up 47 months. Seven (29 %) patients never achieved CR+MRD-. Univariate Cox regression analysis shows CR+MRD- status after mN7 induction as the only statistically significant prognostic factor to predict overall survival. Conclusions. mN7 induction regimen produced a CR+MRD- rate of 71 %. CR+MRD- status following induction was the only predictive marker of long-term survival (AU)

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[Towards a safety culture in the neonatal unit: Six years experience]. / Caminando hacia una cultura de seguridad en la unidad neonatal: experiencia de 6 años.

INTRODUCTION: A safety culture is the collective effort of an institution to direct its resources toward the goal of safety. MATERIAL AND METHODS: An analysis is performed on the six years of experience of the Committee on the Safety of Neonatal Patient. A mailbox was created for the declaration of adverse events, and measures for their correction were devised, such as case studies, continuous education, prevention of nosocomial infections, as well as information on the work done and its assessment. RESULTS: A total of 1287 reports of adverse events were received during the six years, of which 600 (50.8%) occurred in the neonatal ICU, with 15 (1.2%) contributing to death, and 1282 (99.6%) considered preventable. Simple corrective measures (notification, security alerts, etc.) were applied in 559 (43.4%), intermediate measures (protocols, monthly newsletter, etc.) in 692 (53.8%), and more complex measures (causal analysis, scripts, continuous education seminars, prospective studies, etc.) in 66 (5.1%). As regards nosocomial infections, the prevention strategies implemented (hand washing, insertion and maintenance of catheters) directly affected their improvement. Two surveys were conducted to determine the level of satisfaction with the Committee on the Safety of Neonatal Patient. A rating 7.5/10 was obtained in the local survey, while using the Spanish version of the Hospital Survey on Patient Safety Culture the rate was 7.26/10. CONCLUSIONS: A path to a culture of safety has been successfully started and carried out. Reporting the adverse events is the key to obtaining information on their nature, etiology and evolution, and to undertake possible prevention strategies.

Results of induction chemotherapy in children older than 18 months with stage-4 neuroblastoma treated with an adaptive-to-response modified N7 protocol (mN7).

PURPOSE: We report the response rate in children older than 18 months with stage 4 Neuroblastoma, using a modified dose-intensive, response-adaptive, induction mN7 protocol. METHODS: From 2005 to 2012, 24 patients were treated with the mN7 protocol. Phase 1 included five MSKCC N7 cycles and surgery and two high-dose cyclophosphamide-topotecan (HD-CT) cycles for those who did not achieve complete remission (CR) and negative bone marrow (BM) minimal residual disease (MRD) status (CR+MRD-). Phase 2 consisted of myeloablative doses of topotecan, thiotepa and carboplatin plus hyperfractionated RT. Phase 3 included isotretinoin and 3F8 immunotherapy plus GM-CSF. BM MRD was monitored using GD2 synthase, PHOX2B and cyclin D1 mRNAs. RESULTS: After 3 cycles, all patients showed BM complete histological clearance and 6 (25 %) were MRD-. Twenty of 21 s-look surgeries achieved macroscopic complete resection. After 5 cycles and surgery, (123)I-MIBG scan was negative in 15 (62.5 %) cases, BM disease by histology was negative in 23 (96 %) and 10 (42 %) patients were MRD-. Twelve (50 %) pts were in CR, 2 in very good partial response (VGPR), 9 partial response (PR) and one had progressive disease. With 2 HD-CT extra cycles, 17 (71 %) pts achieved CR+MRD- status moving to phase 2. Overall and event-free survival at 3 years for the 17 patients who achieved CR+MRD- is 65 and 53 %, respectively, median follow-up 47 months. Seven (29 %) patients never achieved CR+MRD-. Univariate Cox regression analysis shows CR+MRD- status after mN7 induction as the only statistically significant prognostic factor to predict overall survival. CONCLUSIONS: mN7 induction regimen produced a CR+MRD- rate of 71 %. CR+MRD- status following induction was the only predictive marker of long-term survival.

Entrenamiento en laparoscopia y apendicitis / Training in laparoscopy and appendicitis

Introducción. Para la formación en laparoscopia, la apendicectomía es la intervención más utilizada, por su alta frecuencia y, habitualmente, escasa dificultad. Sin embargo, durante la curva de aprendizaje (las primeras 35 intervenciones), el número de complicaciones puede aumentar, con lo que el beneficio de la formación se puede convertir en perjuicio para algunos pacientes. Por ello hemos revisado las complicaciones graves de las apendicectomías laparoscópicas realizadas en nuestro Servicio antes y después de la curva de aprendizaje y las hemos comparado entre sí y con las de las apendicectomías abiertas. Material y métodos. Se han revisado las complicaciones graves (abscesos intraabdominales, oclusiones, hemorragias, etc..) de las 1.710 apendicectomías realizadas en nuestro centro desde 1997 hasta 2013, divididas en tres grupos: abiertas (AA, n = 1.258), laparoscópicas durante la curva de aprendizaje (LDC, n = 154) y laparoscópicas tras la curva de aprendizaje (LTC, n = 298). Se han dividido en apendicitis simples (n = 1.233) y peritonitis (n = 477). Resultados. En el grupo AA se detectaron 110/1.258 complicaciones graves (8,7%), en el grupo LDC 28/154 (18,2%) y en el grupo LTC, 19/298 (6,4%) (p< 0,05 LDC vs AA y LTC). En las apendicitis simples las complicaciones fueron 13/889 (1,5%), en las AA 3/115 (2,6%) en el grupo LDC, y 2/229 en el grupo LTC (0,9%) (p = ns LDC vs AA y LTC). En las peritonitis las complicaciones fueron 97/369 (26,3%) en las AA, 25/39 (64%) en el grupo LDC y 17/69 (24,6%) en el grupo LTC (p< 0,05 LDC vs AA y LTC). Conclusiones. La apendicectomía laparoscópica con fines formativos debería reservarse a los casos de apendicitis simples

Background. In order to improve laparoscopic skills, appendectomy is the most common procedure because of its high frequency and low difficulty. In spite of that, during the learning curve (each surgeon´s first 35 interventions) the incidence of complications may increase, so improvement in training means a bigger risk for some patients. Methods. We retrospectively reviewed major complications (intra-abdominal abscess, intestinal occlusion, hemorrhage) of 1,710 appendectomies performed at our service between 1997 and 2013. We divided them in three groups: open appendectomy (OA, n= 1,258), laparoscopic appendectomy during the learning curve (LDC, n= 154) and laparoscopic appendectomy after the learning curve (LAC, n= 298). In addition, we distinguish between simple appendicitis (n= 1,233) and peritonitis (n= 477). Results. In the OA group we detected110/1,258 major complications (8.7%), 28/154 major complications (18.2%) in the LDC group and 19/298 (6.4%) in the LAC group (p< 0.05 LDC vs OA and LAC). In the simple appendicitis group, we found 13/889 major complications (1.5%) in OA, 3/115 (2.6%) in LDC group and 2/229 (0.9%) in LAC group (p= ns LDC vs OA and LAC). In the peritonitis group, 97/369 (26.3%) major complications were found in OA group, 25/39 (64%) in LDC group and 17/69 (24.6%) in LAC group (p< 0.05 LDC vs OA and LAC). Conclusions. Educational purpose laparoscopic appendectomy must be used in simple appendicitis cases

[Training in laparoscopy and appendicitis]. / Entrenamiento en laparoscopia y apendicitis.

BACKGROUND: In order to improve laparoscopic skills, appendectomy is the most common procedure because of its high frequency and low difficulty. In spite of that, during the learning curve (each surgeon´s first 35 interventions) the incidence of complications may increase, so improvement in training means a bigger risk for some patients. METHODS: We retrospectively reviewed major complications (intra-abdominal abscess, intestinal occlusion, hemorrhage) of 1,710 appendectomies performed at our service between 1997 and 2013. We divided them in three groups: open appendectomy (OA, n= 1,258), laparoscopic appendectomy during the learning curve (LDC, n= 154) and laparoscopic appendectomy after the learning curve (LAC, n= 298). In addition, we distinguish between simple appendicitis (n= 1,233) and peritonitis (n= 477). RESULTS: In the OA group we detected110/1,258 major complications (8.7%), 28/154 major complications (18.2%) in the LDC group and 19/298 (6.4%) in the LAC group (p<0.05 LDC vs OA and LAC). In the simple appendicitis group, we found 13/889 major complications (1.5%) in OA, 3/115 (2.6%) in LDC group and 2/229 (0.9%) in LAC group (p= ns LDC vs OA and LAC). In the peritonitis group, 97/369 (26.3%) major complications were found in OA group, 25/39 (64%) in LDC group and 17/69 (24.6%) in LAC group (p<0.05 LDC vs OA and LAC). CONCLUSIONS: Educational purpose laparoscopic appendectomy must be used in simple appendicitis cases.

INTRODUCCION: Para la formación en laparoscopia, la apendicectomía es la intervención más utilizada, por su alta frecuencia y, habitualmente, escasa dificultad. Sin embargo, durante la curva de aprendizaje (las primeras 35 intervenciones), el número de complicaciones puede aumentar, con lo que el beneficio de la formación se puede convertir en perjuicio para algunos pacientes. Por ello hemos revisado las complicaciones graves de las apendicectomías laparoscópicas realizadas en nuestro Servicio antes y después de la curva de aprendizaje y las hemos comparado entre sí y con las de las apendicectomías abiertas. MATERIAL Y METODOS: Se han revisado las complicaciones graves (abscesos intraabdominales, oclusiones, hemorragias, etc..) de las 1.710 apendicectomías realizadas en nuestro centro desde 1997 hasta 2013, divididas en tres grupos: abiertas (AA, n= 1.258), laparoscópicas durante la curva de aprendizaje (LDC, n= 154) y laparoscópicas tras la curva de aprendizaje (LTC, n= 298). Se han dividido en apendicitis simples (n= 1.233) y peritonitis (n= 477). RESULTADOS: En el grupo AA se detectaron 110/1.258 complicaciones graves (8,7%), en el grupo LDC 28/154 (18,2%) y en el grupo LTC, 19/298 (6,4%) (p<0,05 LDC vs AA y LTC). En las apendicitis simples las complicaciones fueron 13/889 (1,5%), en las AA 3/115 (2,6%) en el grupo LDC, y 2/229 en el grupo LTC (0,9%) (p= ns LDC vs AA y LTC). En las peritonitis las complicaciones fueron 97/369 (26,3%) en las AA, 25/39 (64%) en el grupo LDC y 17/69 (24,6%) en el grupo LTC (p>;0,05 LDC vs AA y LTC). CONCLUSIONES: La apendicectomía laparoscópica con fines formativos debería reservarse a los casos de apendicitis simples.

Molluscum contagiosum congénito / Congenital Molluscum Contagiosum

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Tratamiento y seguimiento del plastrón apendicular / Management of appendicular mass

Introducción. El tratamiento del plastrón apendicular continúa siendo controvertido. Hay autores que defienden un tratamiento conservador inicial seguido de una apendicectomía programada. Objetivos. Nuestro propósito ha sido analizar la utilidad de este tratamiento y el momento óptimo para la intervención. Material y métodos. Se trata de un estudio retrospectivo de los casos tratados en nuestro Hospital durante los últimos 8 años. Se han analizado: tasa de éxito del tratamiento conservador, tiempo de espera hasta la apendicectomía, dificultad técnica y complicaciones. Resultados. Nuestra serie incluye 19 casos. En todos ellos se administró antibioterapia intravenosa y, en 14 de ellos, además, se realizó drenaje peritoneal (estancia media de 11,5 días). En 3 pacientes (16%) fue necesario realizar la apendicectomía de manera precoz (a los 12, 30 y 40 días). En 16 (84%), el manejo conservador funcionó y la apendicectomía se realizó transcurridos entre 3 y 12 meses (media: 6,6 meses): cuatro por abordaje abierto y 12 mediante laparoscopia (siendo necesario reconvertirla en 3 casos). La estancia media fue de 1,8 días, con sólo una complicación (absceso de pared). De los 16 casos, en 11 la intervención fue sencilla (no adherencias o leves) y el tiempo medio de espera fue de 5,5 meses (rango 3-6). En 5 casos había muchas adherencias, la intervención fue difícil y la espera media de 9,4 meses (rango 9-12).Conclusiones. El manejo conservador es una opción eficaz de tra tamiento para el plastrón apendicular, con una tasa de éxito del 84% en nuestra serie. Según nuestra experiencia, la apendicectomía resulta más sencilla cuando se realiza entre 3-6 meses (AU)

Objectives. Our aim has been to revise the usefulness of this management and the optimal time to carry out the appendectomy. Methods. We made a retrospective review of all the appendicular mass cases treated in our hospital during the last 8 years. We analyzed the success rate of the non-operative approach, the interval until the delayed appendectomy was performed, difficulty found at surgery and the occurred complications. Results. Our series includes 19 appendicular mass cases managed initially by a non-operative approach. Intravenous antibiotics were administered to all of them and in 14 cases a peritoneal drainage was placed (the average length of stay was of 11.5 days). In 3 cases (16%) early appendectomy was performed (12, 30 and 40 days after the onset of the symptoms). In 16 (84%) the conservative approach succeeded and the appendectomy was delayed 3-12 months (average: 6.6 months). Four of them were performed by an open approach and 12 by laparoscopy (in 3 of which conversion was needed). The average length of stay was of 1.8 days, with only one complication (wound abscess). Of these 16 delayed appendectomies, 11 were not technically difficult to perform (average wait of 5.5 months) and in 5 cases the procedure was difficult due to multiple adhesions (average wait of 9.4 months).Conclusion: Conservative management of appendicular mass is useful, with a success rate of 84% in our series. The appendectomy was less hazardous if performed 3-6 months after the onset of the symptoms (AU)

La esperanza desde una perspectiva profesional / Hope from the professional´s perspective

Fundamento. La esperanza, entendida como la confianza en el futuro, requiere la participación activa de la persona, por tanto, es un valor que hay que cultivar. Objetivo. Responder a las preguntas: ¿Puede existir esperanza en medio del sufrimiento? ¿Cuál es la responsabilidad de los profesionales de la salud cuando se trata de esperanza? Método. Revisión bibliográfica y reflexión. Resultados. Ante el sufrimiento, la respuesta no debe ser la huida, sino la esperanza, enfrentarse a él reconociéndolo, rendirse a la L’esperança des d’una perspectiva professional M. Glòria Moretones-Suñol, M. Teresa Esqué-Ruiz Servei de Neonatologia. Hospital Clínic - Maternitat. ICGON. Barcelona evidencia y trascenderlo, haciendo una interpretación positiva que permita reconocer el potencial de crecimiento personal. En el ámbito de la salud, la esperanza del enfermo no sólo se refiere a la curación, sino a que se le tratará con respeto y no se le abandonará. Los profesionales tenemos una responsabilidad con los pacientes en el esfuerzo de reconducir la esperanza, fortaleciendo la confianza en sí mismos y en los profesionales, ayudando a contemplar las posibilidades y alternativas, clarificando las opciones, transmitiendo futuro real, sin falsas expectativas ni espejismos. Se puede resumir en: presencia, disponibilidad, escucha, acompañamiento y compromiso. Se trata de la realización de los valores fundamentales de la profesión. Conclusiones. El ser humano es más profundo de lo que aparenta, y capaz de realizarse a través de las crisis de la vida (AU)

Background. Hope, understood as trust in the future, requires the active participation of the individual; therefore it is a value that needs to be nurtured. Objective. To answer to the questions ‘Could hope exist in the midst of suffering?’ and ‘What is the responsibility of healthcare providers in providing hope?’ Method. Literature review and personal considerations. Results. When facing suffering, the response should not be to flee but to hope, recognizing and facing it, surrendering to the evidence, and going beyond to make a positive interpretation, which recognizes the potential for personal growth. In the field of health services, hope does not only refer to healing of the patient, but also to the respectful treatment and constant support. Professionals have a responsibility towards patients to bring back hope, help build self-confidence and trust in the professionals, help see clearly, consider the possibilities and alternatives, and transmit real future possibilities without false expectations and delusions. The healthcare provider’s role can be summarized as presence, availability, listening, support, and commitment; these are the fundamental values of the profession. Conclusions. The human being is greater and deeper than it appears, and is capable of overcoming life’s crises (AU)

Dimensión ética de la seguridad asistencial / Ethical issues in healthcare safety

Fundamento. La seguridad es una característica esencial de la asistencia sanitaria. Los humanos se equivocan, el conjunto de la atención sanitaria es muy complejo y la práctica clínica depende tanto de la capacidad de análisis del profesional como de circunstancias externas. El riesgo y la incertidumbre, pues, acompañan a la práctica clínica. Trabajar por la seguridad consiste en gestionar el riesgo y reducir la incertidumbre mediante el conocimiento, el razonamiento y la deliberación prudente. De la misma manera, el proceso para llegar a conocer la bondad moral de los actos es un Dimensió ètica de la seguretat assistencial M. Glòria Moretones-Suñol Servei de Neonatologia. Hospital Clínic-Maternitat. ICGON. Barcelona proceso intelectual constituido por el conocimiento, la reflexión y la deliberación. Objetivo. Argumentar y aportar datos para la reflexión sobre la dimensión ética de la seguridad del paciente. Método. Estudio y reflexión en torno a cuatro aspectos de la ética: valores, principios, responsabilidad y respeto. Conclusiones. Todo sistema de gestión del riesgo asistencial debe incluir la aceptación de unos valores que guíen el trabajo de los profesionales y los responsabilicen en la salvaguarda de la seguridad. Salvaguarda que está vinculada al respeto al principio de autonomía, ligado indisolublemente al principio de beneficencia y a la información entendida como diálogo. La responsabilidad constituye el centro de la moral profesional, modula la libertad y el poder del ser humano sobre el ser humano. La aproximación al otro con respeto es fuente de sentido y de orientación, vincula y ayuda a concentrarse en lo importante(AU)

Background. Safety is an essential component of healthcare. Humans make mistakes and healthcare is complex. Clinical practice depends on the professional ability to analyze and consider external circumstances. Therefore, risk and uncertainty go hand in hand with clinical practice. Security implies managing risk, and reducing uncertainty, through knowledge, reasoning and prudent deliberation. Similarly, understanding the moral goodness of actions is an intellectual process consisting of knowledge, reflection and deliberation. Objective. To argue and provide data for reflection regarding the ethical dimension of patient safety. Methodology. A study and reflection regarding four aspects of ethics: values, principles, responsibility and respect. Conclusions. Any healthcare risk management system should include the acceptance of values that guide the work of healthcare professionals and involve them in safeguarding patients. This is linked to respect for the principles of autonomy and beneficence and to information understood as a dialogue. Responsibility lies in the center of the professional moral, and it modulates the freedom and the power of man over man. The approach to the “other” with respect is a source of meaning and orientation, and helps you focus on what is important(AU)

[Management of appendicular mass]. / Tratamiento y seguimiento del plastrón apendicular.

BACKGROUND: Management of appendicular mass is still controversial. Some authors plead for an initial non-operative approach followed by a delayed appendectomy. OBJECTIVES: Our aim has been to revise the usefulness of this management and the optimal time to carry out the appendectomy. METHODS: We made a retrospective review of all the appendicular mass cases treated in our hospital during the last 8 years. We analyzed the success rate of the non-operative approach, the interval until the delayed appendectomy was performed, difficulty found at surgery and the occurred complications. RESULTS: Our series includes 19 appendicular mass cases managed initially by a non-operative approach. Intravenous antibiotics were administered to all of them and in 14 cases a peritoneal drainage was placed (the average length of stay was of 11.5 days). In 3 cases (16%) early appendectomy was performed (12, 30 and 40 days after the onset of the symptoms). In 16 (84%) the conservative approach succeeded and the appendectomy was delayed 3-12 months (average: 6.6 months). Four of them were performed by an open approach and 12 by laparoscopy (in 3 of which conversion was needed). The average length of stay was of 1.8 days, with only one complication (wound abscess). Of these 16 delayed appendectomies, 11 were not technically difficult to perform (average wait of 5.5 months) and in 5 cases the procedure was difficult due to multiple adhesions (average wait of 9.4 months). CONCLUSION: Conservative management of appendicular mass is useful, with a success rate of 84% in our series. The appendectomy was less hazardous if performed 3-6 months after the onset of the symptoms.

¿Debemos informar al paciente cuando sucede un error asistencial? Apuntes para la reflexión / Should we inform the patient when a medical error occurs? Food for thought

Fundamento. La seguridad asistencial pasa por el compromiso de todos los estamentos de la asistencia sanitaria con los valores de la cultura de seguridad. Uno de estos valores es la transparencia, es decir, informar al paciente cuando existe un cambio no deseado en su proceso clínico. Objetivo. Argumentar y ofrecer datos para la reflexión sobre la necesidad de informar al paciente cuando sucede un error asistencial grave. Método. Revisión bibliográfica. Hem d’informar el pacient quan succeeix un error assistencial? Apunts per a la reflexió M. Glòria Moretones-Suñol, Josep Figueras-Aloy, Sandra Parés-Tercero, Rocío Cortés-Albuixech, Lourdes Arroyo-Gili, M. Teresa Esqué-Ruíz Servei de Neonatologia. Hospital Clínic-Maternitat. ICGON. Barcelona Resultados. Se organizan en 5 apartados que se refieren al paciente, el profesional, aspectos legales, ética y repercusión sobre la seguridad asistencial. Conclusiones. La mayor parte de los pacientes desean ser informados. Cuando el profesional se equivoca con consecuencias graves para la salud del paciente, las emociones negativas y los prejuicios obstaculizan el camino hacia la resolución del error abocando a su perpetuación. Hablar con el paciente ayuda a recuperar la confianza en uno mismo y refuerza la relación. No hablar del error pone los propios intereses por delante de los del paciente y viola los principios éticos de la profesión. El cambio a favor de la seguridad requiere estrategias que no culpabilicen y basadas en la confianza, con el compromiso de pacientes, organizaciones, profesionales y sociedad. Los profesionales deberían ser instruidos en cómo hacer frente a la situación con actitud respetuosa y dialogante, y a pedir perdón(AU)

Background. Patient safety needs the commitment of all health care levels with the values of a safety culture. One of those values is transparency, i.e., to inform the patient when there is an unwanted change in their clinical process. Objective. To review and analyze data on the need to inform the patient when a medical error has occurred. Method. Literature review. Results. The paper is organized in five sections that refer to the patient, the health care provider, the legal aspects, the ethics, and the impact on safety. Conclusions. Most patients would like to be kept informed. When medical errors with serious consequences for the patient occur, the negative emotions and the prejudices that follow obstruct the proper resolution of the error, thus leading to its perpetuation. To inform the patient helps recover the self-confidence and strengthens the relationships. To avoid discussing the error places the provider’s own interests above the patient’s and violates the ethical principles of the profession. Improvements in patient safety require trust-based strategies that do not penalize, and that integrate a compromise of patients, healthcare organizations and providers, and society. The healthcare professionals should be trained on how to apologize and deal with this situation with a very respectful attitude(AU)

Facial telangiectasia: an unusual manifestation of neonatal lupus erythematosus.

Neonatal lupus erythematosus (NLE) is an uncommon condition usually associated with maternal anti-Ro autoantibodies. The cutaneous lesions of NLE are usually transient, disappearing about six months after birth, but telangiectasia is a rare complication of NLE which persists. Telangiectasias are small focal red macules and papules created by abnormally prominent capillaries, venules, and arterioles and are a characteristic marker of connective tissue diseases. We report the case of an infant diagnosed with NLE presenting typical annular lesions, positive ANA and positive anti-Ro antibodies. By five months of age, both ANA and anti-Ro antibodies were negative and the annular cutaneous lesions had gradually faded, but small scattered focal red macules appeared on the face, especially in the peri-orbital area and scalp. The cutaneous lupus disappeared but the telangiectasia persisted. We would like to suggest that the diagnosis of NLE should be considered when cutaneous telangiectasias are observed in infants.

Hysteroscopic diagnosis of uterine sarcomas at the Department of Gynaecology, Sant Joan de Déu University Hospital.

Uterine sarcomas are rare and the clinical diagnosis of sarcoma is difficult. Diagnostic and surgical hysteroscopy is a minimally invasive outpatient procedure that makes an accurate diagnosis of malignant intrauterine pathology and could play a role in the diagnosis of the uterine sarcomas. Uterine sarcomas diagnosed at the Department of Gynecology of Sant Joan University Hospital by hysteroscopy between January 2004 and August 2010 are described. In this period 2,441 hysteroscopies were performed; a total of 67 adenocarcinomas of the endometrium and five sarcomas were diagnosed by hysteroscopy. The data are presented with a review of the literature, focusing on the diagnostic value of hysteroscopy in these tumors.

Hysteroscopic diagnosis of a high-grade endometrial sarcoma in a 41-year-old woman.

Endometrial stromal sarcomas originate in the endometrial cavity. These tumors represent between 15-27.9% of uterine sarcomas. We present the case of a 41-year-old woman who underwent surgical hysteroscopy for metrorrhagia over a period of one month who had an intrauterine polypoid mass detected by ultrasonography. Histologic analysis of the polypoid mass removed by hysteroscopy was a high-grade endometrial stromal sarcoma of the uterus. The description of this case provides an opportunity to review the literature on uterine sarcomas diagnosed by surgical hysteroscopy.

Villoglandular papillary adenocarcinoma of the uterine cervix: a case report and literature review.

Villoglandular papillary adenocarcinoma is an infrequent form of well differentiated cervical papillary adenocarcinoma that has recently been described. It usually affects young women and is distinguished from other adenocarcinomas by its generally good prognosis, since it infrequently invades the lymphovascular space. We present a case of villoglandular papillary adenocarcinoma in a 28-year-old woman presenting risk factors for developing it: use of oral contraceptives, tobacco use, and infection with human papillomavirus types 16 and 33. The presentation of this case provides an opportunity to review the literature on the diagnosis and treatment of villoglandular papillary adenocarcinoma, and the factors that may influence the prognosis of women diagnosed with this histological type of cervical cancer.

[Laparoscopic appendectomy after the learning curve]. / La apendicectomía laparoscópica más allá de la curva de aprendizaje.

BACKGROUND: Despite its increasing popularity, laparoscopic appendectomy does not put an unanimous end to the answer to the best treatment for appendicitis. Although the postoperative stay is shorter, the wound infection practically does not exist and scars are minimal, some publications question its advantages due to the incidence of intra-abdominal absceses, postoperative analgesia requirements and the recently described "postlaparoscopic appendectomy complication" (PLAC), an intra-abdominal infection, without abscess formation, which develops after laparoscopic appendectomy for non-complicated appendicitis. Some of this series include the "learning curve", wherein they compare results of inexperienced surgeons in laparoscopic techniques with those obtained after with the firmly established open appendectomy (OA) technique. With the aim to clarify this aspects, we reviewed our experience in laparoscopic appendectomy during (LDC) and after (LAC) the "learning curve" and we compared their complications with the open appendectomies' ones. METHODS: We retrospectively reviewed 807 appendectomies: 208 laparoscopic (LA) and 599 open (OA) from January 2001 to December 2007 performed in our hospital. In the laparoscopic group, 83 of them (40%) were done during the learning curve (each surgeon's 35 first interventions, LDC) and 125 (60%) after the learning curve (LAC). We have compared both laparoscopic subgroups to each other and to the open appendectomies group. We analysed the age, sex, length of stay, kind of appendicitis (simple or perforated appendicitis) and five of the most serious complications: intra-abdominal abscess, postoperative intestinal occlusion, intestinal perforation, haemorrhage and PLAC. RESULTS: The mean age (9 years), sex (58% men; 42% women) and the peritonitis rate (30%) were similar among the 3 groups. The mean length of stay was reduced from 5.4 days in OA group to 4.2 days in LA group and 3.6 days in LAC group (p < 0.01). The simple appendicitis cases had the shortest length of stay: 3.41 days in OA group and 2.16 days in LA group (p < 0.0001). There were no differences in stay for the peritonitis group. In the OA group, we detected 56 severe complications (9,3%): 49 abcesses, 2 occlusions, 2 PLAC, 1 haemorrhage, 1 intestinal perforation and 1 liver abscess. Nineteen severe complications were found in LDC group (22,9%): 9 abscesses, 4 occlusions, 4 haemorrhages, 1 intestinal perforation and 1 PLAC (p < 0.01 vs OA group). In the LAC group, we found 13 complications (10,4%): 9 abscesses, 1 occlusion, 1 PLAC and 2 haemorrhages (p = 0.3 vs OA group). CONCLUSIONS: 1. The length of stay was significantly reduced in laparoscopic appendectomies. 2. Severe complications, particularly intestinal occlusions and haemorrhages, increased significantly during the learning curve, with a slight fluctuation for intra-abdominal abscesses and PLAC. 3. After the learning curve, complications' global rate was similar to the OA group's, with an increment of haemorrhages and occlusions, no variation for PLAC and a slight reduction for intra-abdominal abscesses. 4. In our experience, laparoscopic appendectomy after the learning curve is the best therapeutic option for acute appendicitis.

Stage 1B cervical cancer in a pregnant woman at 25 weeks of gestation.

Cervical cancer associated with pregnancy is rare (0.05%), although it is the most frequently diagnosed malignancy in pregnant women. We present the case of a 28-year-old woman at 25 weeks of gestation diagnosed with Stage 1B cervical cancer. Treatment was delayed until fetal maturity, and an elective cesarean section was performed at 33 weeks' gestation, followed by a total hysterectomy preserving the ovaries, and a pelvic lymphadenectomy. A review of the literature on the treatment of cervical cancer during pregnancy relevant to the case described is also presented.