Physicians as second victims after a malpractice claim: An important issue in need of attention.

OBJECTIVE: Being sued for malpractice is extremely stressful and potentially traumatizing. We aim to identify claims' consequences on the physicians' well-being and medical practice. MATERIAL AND METHODS: We administered a confidential telephonic survey to those physicians with a claim closed during 2014, among those insured by the main professional liability insurance company in the region. The questionnaire addressed several topics: symptoms and well-being changes, needs, impairments and practice changes. We used descriptive statistics as well as Chi-square and T-Student tests. RESULTS: A total of 99 physicians responded to the questionnaire (response rate of 64.7%). Most of them (80.8%) acknowledged having suffered a significant emotional distress, no matter the claim's outcome (p=0.958) or the kind of procedure (p=0.928). Anger and mood cluster of symptoms were frequent, and the experience frequently affected their personal, family or social life and professional conduct. Practice changes correlated significantly and positively with the number of symptoms reported (p=0.010), but not with the outcome of the claim (p=0.338) or the kind of procedure (p=0.552). CONCLUSIONS: Most claimed physicians suffer a significant emotional distress after a malpractice claim, which affects their professional performance. According to our results, they should be assessed and assisted in order to minimize the negative consequences on their well-being and their praxis.

Análisis de la lipocalina asociada a la gelatinasa de neutrófilos en el paciente crítico / Analysis of neutrophil gelatinase-associated lipocalin in the critical patient

OBJETIVO: Determinar si un valor de NGAL > 150 ng/ml es una buena prueba diagnóstica para detectar precozmente disfunción renal aguda (DRA) en el paciente crítico. DISEÑO: Estudio prospectivo, observacional, de cohorte. Ámbito: Unidad de cuidados intensivos y de cirugía cardíaca del Servicio de Medicina Intensiva del Hospital Germans Trias I Pujol. PARTICIPANTES: Los pacientes ingresados en el Servicio de Medicina Intensiva los días designados en el estudio. INTERVENCIONES: Análisis sanguíneo de la creatinina sérica determinada desde siete días antes del día de inicio del estudio, y diariamente durante cuatro semanas. Determinación de NGAL mediante prueba de orina, en muestra congelada, con el analizador ARCHITECT (Abbott diagnostics)por inmunoanálisis determinado el día de inicio del estudio y dos veces a la semana durante cuatro semanas, análisis de la estancia y mortalidad. RESULTADOS: Se obtuvieron 529 muestras de NGAL de 46 pacientes. El 37% de los pacientes presentaron un valor de NGAL > 150 ng/ml. La sensibilidad de la prueba para diagnosticar DRA fue del 69%, la especificidad fue del 75,7%. Sin embargo, el valor predictivo positivo fue del53%, lo cual significa que el 47% de los pacientes con NGAL alto no desarrollaron DRA. Un NGAL > 150 mg/dL se asoció de manera significativa a un SOFA más alto y a una estancia más larga en UCI. La mortalidad de los pacientes con NGAL elevado fue del 58,8%. CONCLUSIONES: Un NGAL > 150 ng/mL no parece ser una excelente prueba para detectar DRA enel paciente crítico pero si que se asocia con un peor pronóstico

OBJECTIVE: To determine if NGAL value exceeding 150 ng/mL is a good diagnostic test for acuterenal failure in critically ill patients. DESIGN: Prospective, observational cohort. SETTING: Intensive Care Unit and Cardiac Surgery Intensive Care Service at Hospital Germans Trias I Pujol. PARTICIPANTS: Patients admitted to the Intensive Care department the Designated days in the studio. INTERVENTIONS: Analysis of serum creatinine blood given from 7 days prior to the start of the study, and daily during 4 weeks and by determination of NGAL urine test in frozen sample, analyzer ARCHITECT (Abbott Diagnostics) determined by immunoassay the day baseline and 2 times a week for 4 weeks, analysis of the stay and mortality. RESULTS: A total of 529 NGAL samples were obtained from 46 patients. 37% of patients had a value of NGAL > 150 ng/mL. The Sensivity of the test to diagnose acute renal failure was 69%, Specifity was 75,7%. However, the Positive Predictive Test Value was 53%, which means that47% of patients with high NGAL did not develop AKI. A NGAL > 150 mg/dL was associated with a significantly higher SOFA and a longer stay in the ICU. The mortality of patients with elevated NGAL was 58.8%. CONCLUSIONS: A NGAL > 150 ng/mL does not seem to be an excellent test for AKI in critically lll patients but is associated with a worse prognosis

[Analysis of neutrophil gelatinase-associated lipocalin in the critical patient]. / Análisis de la lipocalina asociada a la gelatinasa de neutrófilos en el paciente crítico.

OBJECTIVE: To determine if NGAL value exceeding 150 ng/mL is a good diagnostic test for acute renal failure in critically ill patients. DESIGN: Prospective, observational cohort. SETTING: Intensive Care Unit and Cardiac Surgery Intensive Care Service at Hospital Germans Trias I Pujol. PARTICIPANTS: Patients admitted to the Intensive Care department the Designated days in the studio. INTERVENTIONS: Analysis of serum creatinine blood given from 7 days prior to the start of the study, and daily during 4 weeks and by determination of NGAL urine test in frozen sample, analyzer ARCHITECT (Abbott Diagnostics) determined by immunoassay the day baseline and 2 times a week for 4 weeks, analysis of the stay and mortality. RESULTS: A total of 529 NGAL samples were obtained from 46 patients. 37% of patients had a value of NGAL>150 ng/mL. The Sensivity of the test to diagnose acute renal failure was 69%, Specifity was 75,7%. However, the Positive Predictive Test Value was 53%, which means that 47% of patients with high NGAL did not develop AKI. A NGAL >150 mg/dL was associated with a significantly higher SOFA and a longer stay in the ICU. The mortality of patients with elevated NGAL was 58.8%. CONCLUSIONS: A NGAL>150 ng/mL does not seem to be an excellent test for AKI in critically ill patients but is associated with a worse prognosis.

[Evaluation of the efficiency of care in the ICU]. / Evaluación de eficiencia asistencial en UCI.

OBJECTIVE: To evaluate the efficiency of care in the ICU using a predictive model. DESIGN: A prospective, observational cohort study SETTINGS: Seventeen Spanish polyvalent ICUs. PATIENTS: A total of 1956 patients were initially considered (cohort A). Posteriorly, and at 6-year intervals, we documented cohorts B (n=453), C (n=2567) and D (n=711) in one of the studied ICUs. METHOD: Five standard severity indices were calculated for all cohorts, and with these the standardized mortality ratios (observed/calculated) for each cohort were compared. Multiple regression analysis was used to develop a predictive model of length of stay in the ICU (ICU-LOS). This model was used for calculation of the standardized LOS ratios for each cohort. We analyzed the organizational changes in the studied ICU during these periods in relation to the results obtained. RESULTS: The calculated probability of in-hospital death was 15.4%, versus 14.7% as calculated 24 hours after admission. Actual in-hospital mortality was 20.3%. A final multiple regression model was constructed. Standardized LOS and mortality ratios were 1.8 and 1.2 (cohort B), 0.97 and 1.07 (cohort C), and 0.63 and 1.07 (cohort D), respectively. The progressive improvement in the results observed was related to the introduced organizational and structural changes. CONCLUSIONS: The model developed in this study was a good predictor of actual ICU-LOS, and both LOS and mortality analysis could be a good tool for ICU care evaluation.

Estudio sobre la correlación clínico-patológica en el síndrome de distrés respiratorio agudo secundario / Study on the clinicopathological correlation in the secondary acute respiratory distress syndrome

Objetivo El objetivo principal del estudio es analizar la correlación clínicopatológica en el diagnóstico de síndrome de distrés respiratorio agudo (SDRA) de origen extrapulmonar. Diseño Se trata de un estudio observacional de una serie de casos. Ámbito UCI de 22 camas de un hospital universitario con 450 camas. Pacientes Diecisiete pacientes fallecidos a causa de un SDRA secundario. Intervención Análisis histopatológico sistemático de todos los lóbulos pulmonares de pacientes que fallecieron en nuestra UCI con el diagnóstico clínico de SDRA secundario y en los que se realizó necropsia entre los años 1999 y 2009. A fin de analizar el grado de correlación entre el diagnóstico clínico y el patológico se aplicó el análisis de kappa. Resultados En 17 pacientes con SDRA secundario la necropsia permitió confirmar 2 casos falsos positivos (11%). El valor kappa fue de 0,77, por lo que el análisis de concordancia fue considerado como satisfactorio. Conclusiones Los criterios clínicos para el diagnóstico de SDRA se correlacionan bien con la presencia de daño alveolar agudo en el estudio patológico necrópsico en pacientes con SDRA secundario, aunque pueden detectarse algunos casos falsos positivos (AU)

Objective This study has aimed to study the clinicopathological correlation of patients with secondary acute respiratory distress syndrome (ARDS), specifically having extrapulmonary causes. Setting A 22 beds intensive care unit. Design An observational study of case series. Patients Seventeen patients whose death was caused by acute respiratory distress syndrome were included. Intervention A systematic histopathological study was made of all the pulmonary lobes of patients who died in our ICU with the clinical diagnosis of secondary ARDS, who had undergone an autopsy between 1999 and 2009. The Kappa analysis was used to analyze the grade of correlation between the clinical and the pathological diagnosis. Results The autopsy confirmed to cases of false positive in 17 patients with ARDS (11%). The kappa value was 0.77, so that the concordance analysis was considered to be satisfactory. Conclusions The clinical criteria for ARDS correlate well with acute alveolar damage (AAD) in the autopsy study in patients with secondary ARDS, although some false positive cases can be observed (AU)

[Study on the clinicopathological correlation in the secondary acute respiratory distress syndrome]. / Estudio sobre la correlación clínico-patológica en el síndrome de distrés respiratorio agudo secundario.

OBJECTIVE: This study has aimed to study the clinicopathological correlation of patients with secondary acute respiratory distress syndrome (ARDS), specifically having extrapulmonary causes. SETTING: A 22 beds intensive care unit. DESIGN: An observational study of case series. PATIENTS: Seventeen patients whose death was caused by acute respiratory distress syndrome were included. INTERVENTION: A systematic histopathological study was made of all the pulmonary lobes of patients who died in our ICU with the clinical diagnosis of secondary ARDS, who had undergone an autopsy between 1999 and 2009. The Kappa analysis was used to analyze the grade of correlation between the clinical and the pathological diagnosis. RESULTS: The autopsy confirmed to cases of false positive in 17 patients with ARDS (11%). The kappa value was 0.77, so that the concordance analysis was considered to be satisfactory. CONCLUSIONS: The clinical criteria for ARDS correlate well with acute alveolar damage (AAD) in the autopsy study in patients with secondary ARDS, although some false positive cases can be observed.

[Patients with acute coronary syndrome: therapeutic approach (management patterns) and 1-year prognosis in a tertiary general hospital]. / Pacientes con síndrome coronario agudo: abordaje terapéutico (patrones de manejo) y pronóstico al año en un hospital general terciario.

BACKGROUND: To assess the determinants of short-term and one-year prognosis of all patients with suspected acute coronary syndrome seen by the cardiologist on duty in the Emergency Service of a tertiary hospital during a six month period. PATIENTS AND METHODS: 153 consecutive patients with a diagnosis of acute myocardial infarction, 225 with a diagnosis of unstable angina and 89 with a diagnosis of atypical chest pain were identified and their in-hospital characteristics and one-year prognosis were prospectively assessed. RESULTS: Age was higher than 65 years in 53% of acute myocardial infarction and in 54% of unstable angina patients. Only 3 patients were lost to follow-up. 35% of acute myocardial infarction patients had died or had reinfarction after one year and 16% of unstable angina patients had died or had suffered acute myocardial infarction. Baseline features, management patterns and prognosis of patients admitted with acute myocardial infarction to the Cardiology Service, to other hospital areas or to other hospitals were markedly different, and admission in areas other than the Cardiology Service was an independent mortality predictor. In unstable angina, complications happened in patients older than 75 years, those with previous revascularization procedures, those undergoing revascularization or those with lesions not deemed revascularizeable. CONCLUSIONS: a) In the study population there was a predominance of elderly patients; the proportion of patients with poor prognosis was considerably high; b) a sizeable proportion of patients with severe complications was scarcely represented in the major clinical trials; c) the possibility arises of a distribution of care resources tending to concentrate the greater therapeutic efforts in the patients with good prognosis.

Evaluation of the use of three different devices for nocturnal oxygen therapy in COPD patients.

OBJECTIVE: To determine whether transtracheal catheter and reservoir nasal cannula contribute to maintaining adequate oxygen saturation during sleep, and to calculate the oxygen saving they allow compared to nasal prongs. DESIGN: A prospective study in which patients were randomly assigned to either nasal prongs or oxymizer device prior to transtracheal oxygen delivery. Arterial oxygen saturation was then monitored by a finger pulse oximeter during 8 h of sleep. SETTING: Pulmonary ward of 'The Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona/Spain)'. PATIENTS: Fourteen stable hypoxemic (PaO2 50 +/- 6.9 mm Hg; PaCO2 51.5 +/- 9.3 mm Hg) COPD patients (FVC 44 +/- 19%; FEV1 26.5 +/- 11.5%; FEV1/FVC 44.9 +/- 9.7%) already receiving oxygen therapy at home. MEASUREMENTS: Pulmonary function test was performed. The lowest flow required to obtain an SaO2 at or above 88% for over 95% of the sleep time was determined for each type of oxygen delivery. Patients were not switched to the next type of oxygen delivery device until 3 reliable pulse oximetries had been obtained. The percentage of oxygen savings was calculated. Awake PaO2 was measured in patients using nasal prongs and transtracheal catheter while continuing to inspire oxygen at the same flow rate as when asleep. RESULTS: As expected, no differences were found in SaO2 measurements for the three types of oxygen delivery. Oxygen savings were 48.65% for the oxymizer device and 52.87% for the transtracheal catheter. Awake PaO2 was significantly higher (p < 0.04) in patients with nasal prongs than in those with transtracheal catheter at the flow rate required when asleep. CONCLUSIONS: The oxymizer device and transtracheal oxygen delivery benefit hypoxemic COPD patients reducing oxygen use during sleep by around 50%. Higher PaO2 levels were necessary to prevent nocturnal SaO2 decreases in patients with nasal prongs than in patients with transtracheal oxygen delivery. Oxygen-conserving devices are reliable and advisable methods for nocturnal oxygenation.

Prognostic factors of pneumonia requiring admission to the intensive care unit.

All patients with severe pneumonias (community-acquired and nosocomial) who required treatment in the intensive care unit (ICU) were included in a 3-year prospective study. Predictive factors for a fatal outcome were analyzed in 127 patients. An etiologic diagnosis was made in 70 (55.1%) patients. Culture of sputum or tracheobronchial secretions were used only as criteria for microbiologic diagnosis of Legionella pneumophila. The pathogens most frequently identified were L pneumophila, Streptococcus pneumoniae, and Pseudomonas aeruginosa. Viruses were not detected as causative agents. A total of 54 patients died (mortality rate, 42.5%). The univariate analysis showed the following factors associated with mortality: advanced age (> or = 70 years); presence of septic shock, requirement of mechanical ventilation, and Simplified Acute Physiology Score [SAPS] index > 12 at the time of admission to the ICU or when symptoms appeared in patients already admitted to the ICU; development of any complication during ICU hospitalization; and P aeruginosa as the etiologic agent of the pneumonia. When all variables were introduced by a stepwise method, the final model included advanced age (> or = 70 years), SAPS index > 12, presence of septic shock, requirement of mechanical ventilation, bilateral pulmonary involvement, and P aeruginosa as the etiologic agent of pneumonia as prognostic factors associated with a fatal outcome.

[Transtracheal catheter and liquid oxygen: 5 years of experience]. / Catéter transtraqueal y oxígeno líquido: 5 años de experiencia.

We studied clinical tolerance, complications, change in pulmonary function test results, arterial gasometrics, hemoglobin (Hb), 6 minute stress tests (6 wt) and subjective perception of dyspnea assessed on a visual analog scale (VAS) in a group of 18 patients (17 with obstructive disease and one with restrictive disease). These patients had previously been enrolled in a home oxygen therapy (HOT) program to deliver continuous oxygen therapy through nasal prongs, and had accepted portable oxygen therapy delivered by transtracheal catheter (TTC) from 1988 until 1993. Tolerance was good, there were no lethal complications of TTC, and excellent compliance with the prescribed HOT was achieved. Lung function test results worsened, while Hb and PaO2 improved and significant oxygen savings (50%) were achieved. The 6 wt test results had not worsened at the end of the first year but did so significantly at the end of the third year, in spite of a relative preservation of lung function. Dyspnea assessed on a VAS was not seen to worsen. We conclude that tolerance of the method was good and that no relevant complications occurred. HOT by TTC did not prevent worsening of bronchial obstruction. Oxygenation of patients was better, as shown by the decrease in Hb and the improvement in PaO2 at the end of the first year of monitoring. Changes in 6 wt showed that in order to achieve greater benefit from HOT by TTC, patients should follow a pulmonary rehabilitation program.

[Intrinsic PEEP as a ventilation complication after pneumonectomy]. / PEEP intrínseca como complicación ventilatoria en el postoperatorio de neumectomía.

We report the case of a female patient who developed a clinical picture characterized by hemodynamic deterioration, bradycardia and asystole due to pulmonary hyperinsufflation (documented by X-ray examination) during the immediate postoperative phase of a right pneumonectomy. Occlusion of the respiratory limb of the respirator was followed by a positive pressure at the end of the respiration (PEEP) suggesting the presence of an intrinsic PEEP independent of the respirator. Application of a PEEP to the respirator induced a radiologic improvement. The mechanisms by which an intrinsic PEEP may develop are discussed.

Hygroscopic condenser humidifier as a solution to nasal dryness due to nasal CPAP treatment for obstructive sleep apnea syndrome.

We report an apparent solution to nasal dryness for patients with obstructive sleep apnea syndrome treated with nasal continuous positive airway pressure (CPAP) when a hygroscopic condenser humidifier is introduced into the CPAP circuit. Six patients underwent a 5-h test period of nasal CPAP therapy with a mask containing a hygroscopic humidifier. The water vapor showed a statistically significant increase in both inspired and expired gases. The relative humidity of the inspired gases increased significantly. The levels of O2 and CO2 in the respired gases did not change. When patients were asked about nasal dryness at the end of the test, all of them reported marked improvement.

Incidence of pneumothorax and pneumomediastinum in patients with aspiration pneumonia requiring ventilatory support.

In a prospective study of patients with ventilatory support, six (38 percent) of 16 patients who had ventilatory support because of aspiration pneumonia developed pneumothorax and pneumomediastinum. In contrast, the incidence of barotrauma in the entire group of patients who had ventilatory support during a year was 4 percent (22/553) (P less than 0.001). This greater incidence in the group with aspiration pneumonia was also observed when patients who were receiving ventilatory support with positive end-expiratory pressure were excluded.