The Patient's Role in Patient Safety.

Keeping patients safe while they receive medical care is essential. Yet current systems designed to ensure patient safety are not enough, because medical error is the third leading cause of preventable deaths in the United States. Clinicians can partner with the patient to enhance patient safety. Pulse Center for Patient Safety proposes patient- and family-driven processes designed to improve a patient's chances of avoiding harm. This article discusses highlights of the role of patient safety through a grassroots lens, summarizes the factors that influence the patient's role in patient safety and reviews recommendations on how clinicians can partner with patients.

Cell proliferation and inflammation on biopsy samples with multifocal atrophic gastritis before and 1 year after Helicobacter pylori eradication.

CONTEXT: Results of clinical trials that have assessed whether gastric cancer is preventable with Helicobacter pylori eradication therapy remain inconclusive. These trials have used atrophy, intestinal metaplasia, and dysplasia as histopathologic end points that reflect possible preneoplastic lesions. Trial results would be more compelling if cell proliferation and inflammatory markers improved simultaneously with histopathologic lesions. OBJECTIVE: To study the presence of cell proliferation markers and type of inflammatory cells in biopsy specimens with gastritis, atrophy, and intestinal metaplasia before and 1 year after H pylori therapy and to determine if immunohistochemistry can be used to study these. DESIGN: We evaluated 12 subjects with gastritis and 16 with gastritis and multiple foci of atrophy and intestinal metaplasia by using immunohistochemical assays for tumor suppressor protein p53, proliferation marker Ki-67, cell cycle regulator cyclin D1, T and B lymphocytes, macrophages, and TUNEL (terminal deoxynucleotide transferase deoxyuridine triphosphate nick end labeling) assay for apoptosis. The biopsy specimens were selected from a randomized clinical trial that studied improvement of histopathologic gastric lesions after H pylori eradication. RESULTS: Groups of surface epithelial cells that expressed p53 and Ki-67 were observed more often in subjects with atrophy and intestinal metaplasia compared with those with gastritis alone. T lymphocytes in the lamina propria were frequently observed 1 year after treatment in subjects with atrophy and intestinal metaplasia. CONCLUSIONS: Immunohistochemical assays for cell proliferation and inflammatory cell markers showed different distribution patterns in these gastric biopsy specimens. The presence of T lymphocytes and groups of cells that expressed proliferation markers in subjects with multiple foci of atrophy and intestinal metaplasia needs further study.

Helicobacter pylori eradication and gastric preneoplastic conditions: a randomized, double-blind, placebo-controlled trial.

Helicobacter pylori causes gastric adenocarcinoma; whether treatment of H. pylori infection prevents this cancer remains unknown. In a randomized, double-blind, placebo-controlled trial of H. pylori eradication, we determined whether treatment for H. pylori decreases gastric cancer risk, using preneoplastic conditions as surrogate markers. A total of 248 healthy volunteers (age >40 years) randomly received H. pylori treatment (omeprazole, amoxicillin, clarythromycin; n = 122) or matched placebo (n = 126) for 1 week. Endoscopy was performed at baseline and at 6 weeks and 1 year. Seven biopsies from each endoscopy were reviewed by two pathologists using the revised Sydney classification. Outcome measures were both a consensus "worst biopsy" diagnosis and a weighted index score that incorporated degrees of severity of preneoplasia from all biopsies. We compared change in these outcomes over time between the two treatment groups. H. pylori cure rates for compliant subjects in the treatment arm were 79.2% and 75.7% at 6 weeks and 1 year, respectively. No statistically significant change in the worst biopsy diagnosis was observed from 6 weeks to 1 year between placebo and treated subjects (for improvement/worsening, placebo, 19.4%/10.5%; treatment, 22.5%/8.3%; P = 0.74). Change in index score was favorably greater in treatment compared with placebo subjects (intention-to-treat analysis, P = 0.03); this finding was particularly evident in the antrum. H. pylori eradication gave more favorable gastric histopathologies over 1 year than no treatment. Such incomplete regression suggests but does not prove that eradication of H. pylori decreases cancer risk.

Diagnostic yield of gastric biopsy specimens when screening for preneoplastic lesions.

The Sydney system recommends sites and numbers of stomach biopsies (mapping) for evaluation of Helicobacter pylori-associated lesions. The diagnostic yield of the recommended mapping technique in populations at high risk for gastric preneoplastic lesions has not been established. We evaluated pathology data from 733 endoscopies performed as part of an intervention study that assessed the effects of H. pylori treatment on preneoplastic conditions. Two pathologists assessed whether the mapping sequence of the 7 biopsy specimens obtained during each endoscopy was correctly followed and graded the specimens using the Sydney classification for gastritis. If the mapping sequence was followed, then we evaluated whether the amount of information obtained from 3 biopsy samples approximated that obtained from 5 and 7 biopsy samples. The mapping sequence was followed in only 239 (33%) endoscopies, indicating that experienced endoscopists can inadvertently misidentify sites in the stomach when obtaining specimens. When data from 7 specimens were used, H. pylori was found in 205 endoscopies, atrophy in 152, metaplasia in 135, and dysplasia in 22. When data from 3 specimens were used, the sensitivity was 99% for presence of H. pylori, 82% for atrophy and metaplasia, and 81% for dysplasia. When data from 5 specimens were used, the sensitivity was 100% for H. pylori, 96% for atrophy, and 95% for metaplasia and dysplasia. Although site-specific biopsy mapping is difficult in practice, the recommendations of the Sydney system as to the location and number of gastric biopsy specimens can adequately identify significant gastric histopathology.

[High frequency of precancerous lesions of gastric cancer associated with Helicobacter pylori and response to treatment, in Chiapas, Mexico]. / Alta frecuencia de lesiones precursoras de cáncer gástrico asociadas a Helicobacter pylori y respuesta al tratamiento, en Chiapas, México.

Stomach cancer is the second cause of death in Mexico in patients with malignant tumors. This disease represents a public health problem. A strong association has been described between chronic infection with Helicobacter pylori and gastric cancer. This malignancy is preceded by a series of preneoplastic conditions, including chronic atrophic gastritis (CAG), intestinal metaplasia (IM), and dysplasia. The objective of this study was to establish the prevalence of preneoplastic conditions associated with infection of Helicobacter pylori in the state of Chiapas and its eradication with antibiotics. Persons infected with Helicobacter pylori and with CAG were identified by serology against CagA protein and serologic levels of gastrin. An endoscopy with biopsy was performed at the beginning of the study, and at 6 weeks and 1 year thereafter. A total of 281 people were enrolled and randomly assigned to treatment or placebo group. CAG was found in 59%, IM in 51%, and dysplasia in 13%. In intent-to-treat and per-protocol analysis, Helicobacter pylori was eliminated in 70 and 76%, respectively. These results indicate high frequency of preneoplastic conditions associated with Helicobacter pylori and an excellent eradication rate. They also offer a possible alternative for preventing gastric cancer.

Eradication rate of Helicobacter pylori in a Mexican population at high risk for gastric cancer and use of serology to assess cure.

OBJECTIVES: Helicobacter pylori causes gastric adenocarcinoma. We assessed the success of H. pylori eradication therapy in a medically underserved population in Chiapas, Mexico, that is at high risk for gastric cancer risk. METHODS: Healthy volunteers with both antibodies to CagA and gastrin levels > or = 25 ng/ml were randomly assigned to receive either a combination of omeprazole, amoxicillin, and clarithromycin or matched placebo for 1 wk. Endoscopy with seven biopsies was performed at baseline, at 6 wk, and 1 yr after treatment. Treatment success was defined as loss of H. pylori by histological analysis. Cure was assessed using change in serology based on the standardized absorbance of a H. pylori ELISA. RESULTS: H. pylori eradication rates were high (intent-to-treat analysis: 76.3% [95% CI = 68.7-84.0%] after 6 wk and 76.1% [95% CI = 67.7-84.6%] after 1 yr; per protocol analysis: 77.8% [95% CI = 70.1-85.4%] after 6 wk and 75.2% [95% CI = 66.5-84.0%] after 1 yr). Nine subjects on active treatment and one subject on placebo who were without H. pylori at 6 wk were infected at 1 yr (recurrence rates 10.7% and 33.3%, respectively, p = 0.31). Median changes in standardized absorbance at 1 yr were 47% and 1% for successfully and unsuccessfully treated patients, respectively. A 10% decline in standardized absorbance after 1 yr had 84% sensitivity and 100% specificity for H. pylori eradication. CONCLUSIONS: Even with a short course of treatment against H. pylori, a high rate of eradication rate can be achieved in populations at high risk for stomach cancer. Serum antibodies are useful in assessing efficacy of therapy.

Validation of Spanish language dyspepsia questionnaire.

No dyspepsia-specific questionnaire currently exists in Spanish. The Spanish Language Dyspepsia Questionnaire (SLDQ) was developed based on Rome dyspepsia criteria, other questionnaires, and common symptoms. Self-reported normal and dyspeptic volunteers (N = 63) in Chiapas, Mexico, participated in a validation study. We assessed intra- and interrater reliability by test-retest studies and established validity by both correlation to the Short Form-36 (SF-36) and comparison of scores between normals and dyspeptics. The total SLDQ score showed a wide distribution (range 0-78, mean 23.7 +/- 21.9). Internal reliability of the SLDQ was high (Cronbach's a = 0.93). Intra- and interrater reliability were excellent (scores from the first and second interviews not statistically different; P = 0.94; intraclass correlation coefficient = 0.96). SLDQ scales correlated appropriately with the SF-36. The SLDQ distinguished self-classified normals from dyspeptics (P < 0.001). The SLDQ fills the unmet need for a valid, reproducible, and multidimensional Spanish-language instrument to measure dyspepsia. Additionally, we have made suggestions for the development of symptom-quantifying questionnaires.

Detection of pulmonary tuberculosis in Chiapas, Mexico.

PURPOSE: To estimate the prevalence of undiagnosed pulmonary tuberculosis (PTB) and the sensitivity of bacilloscopy in the border region of Chiapas, Mexico. METHODS: We actively sought individuals aged 15 years or more with chronic cough from the Border Region of Chiapas, Mexico in three settings: one regional hospital, seven Primary Care Centers (PCC), and 32 communities. Individuals (a total of 899) reporting chronic cough were asked to provide three samples of sputum for acid-fast smears and cultures. The quality of acid-fast smears was evaluated using culture as the gold standard. RESULTS: We obtained sputum specimens from 590 of 899 individuals with chronic cough. A diagnosis of PTB was confirmed in 78. A conservative estimate of the overall prevalence of PTB at the population level was 151 per 100,000 (95% CI: 88 to 241). In the regional hospital, the estimated case detection rate was 66% (29/44). The proportion of candidates for PTB therapy that were actually on treatment was 50% (14/28) at the PCC and 11% (2/19) in the communities. The sensitivity of the bacilloscopy was about 90% in the hospital, and slightly lower than 50% in the PCC and the communities. CONCLUSION: Improved procedures for PTB detection are required in the studied area to adequately control the disease and to provide therapy to affected patients.

Childbirth care-seeking behavior in Chiapas.

This study was designed to better understand how women in a developing region choose between the multiple options available to them for birthing. We conducted focused, open-ended ethnographic interviews with 38 nonindigenous, economically marginal women in Chiapas, Mexico. We found that although medical services for birthing were readily available to them, these women most often chose traditional birth attendants (TBAs) for assistance with their births. They expressed a clear preference for TBAs in the case of a normal birth, but viewed medical services as useful for diagnosing and managing problem deliveries and for tubal ligations. They favored TBAs because they valued being able to choose birthing locations and birthing positions and to have relatives present during the birth, all features they must give up for medically attended births in this region.

Características de la violencia doméstica y las respuestas de las mujeres en una comunidad rural del municipio de Las Margaritas, Chiapas / Characteristics of domestic violence and women's replies in a rural comunity of Las Margaritas, Chiapas

En México casi la mitad de las mujeres sufren violencia doméstica. Pocos estudios abordan esta problemática y la mayoría de ellos se han llevado a cabo en las zonas urbanas. Este estudio pretende conocer más a fondo y en sus contextos particulares las características de la violencia doméstica en una comunidad rural en el Municipio de Las Margaritas, Chiapas. La violencia doméstica es una faceta del problema más amplia de la violencia intrafamiliar. Se define como el conjunto de conductas, acciones u omisiones ejercido contra la mujer por su pareja con el propósito de mantener el control de la relación. Estas acciones incluyen la violencia física, emocional y sexual. Los datos sobre la violencia doméstica muestra una realidad adversa para la mujer a nivel mundial. En 35 estudios revisados en diferentes países, se indicó que entre un cuarto y más de la mitad de las mujeres informan que su pareja había abusado físicamente de ellas. Este trabajo se basa en una investigación de corte cualitativo. Se hicieron entre entrevistas exhaustivas a diez mujeres que refirieron que su pareja abusaba físicamente de ellas. Las entrevistas se enfocaron a los siguientes temas: la formación de las parejas, las características de la violencia conyugal y la respuesta de las mujeres a la violencia doméstica. Los diferentes relatos de las mujeres entrevistadas muestran las formas complejas que adopta la violencia doméstica en esta comunidad. Para la mayoría de las mujeres entrevistadas, la violencia física conyugal es aceptable cuando se utiliza en su contra para corregirlas, pero no es aceptable cuando no existe una justificación, cuando la agresión física es excesiva (que cause heridas que sangren y hagan perder el conocimiento) o cuando la pareja golpeadora se encuentra bajo los efectos del alcohol. Sin embargo la tolerancia a la violencia doméstica no es homogénea, sino que depende de la situación económica, la escolaridad y las redes de apoyo con las que cuentan las mujeres. En este estudio se encontró que las mujeres más favorecidas toleran menos la violencia...