Clinical Usefulness of Bronchoalveolar Lavage in the Management of Pulmonary Infiltrates in Adults with Hematological Malignancies and Stem Cell Transplantation.

INTRODUCTION: Pulmonary complications are frequent in patients with hematologic malignancies and stem cell transplantation. Regardless of the microbiological usefulness of bronchoalveolar lavage (BAL), little information exists on both its benefits as a guide for therapeutic decisions and its impact on patients' clinical outcome. METHODS: A prospective observational single-center study was performed between July 2011 and July 2016. Consecutive episodes of pulmonary infiltrates were analyzed in subjects over 18 years of age who presented hematologic malignancies and underwent chemotherapy or stem cell transplantation. RESULTS: Ninety-six episodes of pulmonary infiltrates were analyzed. Acute leukemia was the most frequent underlying condition. Thirty-seven patients (38.5%) received a stem cell transplant. Sixty-one (62.9%) were neutropenic at the moment of inclusion in the study. A definitive etiologic diagnosis was obtained in 41 cases (42.7%), where infection accounted for the vast majority of cases (33 cases, 80.5%). Definitive diagnosis was reached by non-invasive methods in 13 cases (13.5%). BAL was performed in 47 cases and led to a diagnosis in 40.4% of the cases. BAL results led to therapeutic changes in 27 cases (57.4%), including the addition of new antimicrobials to empiric treatments in 10. Regarding BAL's safety, two patients experienced minor adverse events and one a severe adverse event; no procedure-related deaths were observed. CONCLUSIONS: Infection was the leading cause of pulmonary infiltrates in patients with hematologic malignancies and stem cell transplantation. BAL was a useful decision-making diagnostic tool, with minor adverse events.

Hiperglucemia en salas de internación general: incidencia y predictores de hiperglucemia de estrés / Hyperglycemia in general hospital wards: incidence and predictors of stress hyperglycemia

INTRODUCCIÓN La hiperglucemia en la internación es prevalente y un factor independiente de mal pronóstico. Está indicado el control rutinario de la glucemia en los pacientes diabéticos y prediabéticos conocidos, los que reciben esteroides u octreotide y aquéllos con alimentación enteral o parenteral. Sin embargo, no se encuentra establecida la estrategia para detectar a los pacientes que desarrollarán HS, definida como hiperglucemia transitoria, asociada a la internación, en pacientes no diabéticos. OBJETIVO Estimar la incidencia acumulada de HS en salas de internación general y determinar cuáles son los factores asociados a presentarla. MÉTODOS Estudio de cohorte prospectivo. Se incluyeron de forma consecutiva los pacientes adultos admitidos por motivos médicos agudos a las salas de internación general de cuatro hospitales de la Ciudad de Buenos Aires, Argentina. Se realizaron controles de glucemia durante las primeras 48 horas de internación y dosaje de hemoglobina glicosilada a todos los pacientes, definiéndose así tres grupos: diabéticos conocidos, diabéticos no conocidos (detectados a través de la hemoglobina glicosilada) y no diabéticos. Se pesquisó en este último grupo la ocurrencia de HS y su asociación con características clínicas y bioquímicas. RESULTADOS Se incluyeron 473 pacientes. La incidencia total de hiperglucemia fue del 30%. Entre los no diabéticos, el 19,7% presentó HS, la cual se asocia de forma significativa con el uso de corticoides, anemia al ingreso, score de APACHE elevado, índice de Katz alterado y la presencia de comorbilidades. Se observa una prevalencia de 20% de diabetes en internación, correspondiendo el 10% a diabéticos no conocidos. DISCUSIÓN Aunque no lo suficientemente descripta, la HS resulta una condición frecuente en la internación. Se destaca la necesidad de profundizar su estudio y lograr definir cuáles son los pacientes en riesgo de presentarla

Venous thromboprophylaxis in general surgery ward admissions: strategies for improvement.

OBJECTIVE: To estimate the adherence to institutional venous thromboprophylaxis clinical practice guidelines (CPGs) in general surgery patients and to assess the effectiveness of a multi-strategy improvement intervention. DESIGN: A prospective before-after study. SETTING: Two teaching hospitals located in the city of Buenos Aires, Argentina. PARTICIPANTS: Prescriptions belonging to patients admitted to the general surgery wards were evaluated. INTERVENTION: A multi-strategy intervention that included (i) simplification of institutional CPGs for venous thromboprophylaxis using a single drug at a single dose, based on the American College of Chest Physicians recommendations, (ii) distribution of pocket cards with an algorithm for the implementation of new recommendations to both, physicians and nurses, working in the general surgery units, (iii) educational talks, (iv) paper-based reminders and (v) audit and feedback. MAIN OUTCOME MEASURE: The adherence of the venous thromboprophylaxis prescription to the institutional recommendations. RESULTS: The prescriptions of 100 admitted patients before and 90 after the intervention were included in the analysis. The initial rate of adherence was 31%. After the intervention this rate rose to 71.1% (P< 0.001). The major improvement observed was the reduction in omitted prophylaxis in patients at risk of venous thromboembolism from 45 to 13.3% (P< 0.001). In the adjusted model, prescribing compliance with CPGs was five times more likely during the second stage than during the first stage (OR = 5.60, 95% CI = 2.92-10.74). CONCLUSIONS: Simple and economical interventions such as those described in this study can improve general surgeons compliance with the institutional and international guidelines, thus assuring patient safety and quality of health care.

Acceso a la información sobre seguridad del paciente: desarrollo de una plataforma para facilitar la gestión del conocimiento / Access to information on patient safety: development of a platform to facilitate knowledge management

INTRODUCCION: La seguridad del paciente ha cobrado mayor relevancia en los últimos años. La acumulación de información y conocimientos demanda la sistematización, traducción y adecuación a los contextos locales para obtener un mejor aprovechamiento. Desde su sitio web, la Academia Nacional de Medicina ha logrado construir una red de usuarios con más de 5.000 personas. El sitio fue desarrollado con un enfoque comunicacional unidireccional, dirigido a efectores de salud y no al público en general.OBJETIVO: Desarrollar a través de las redes sociales una comunidad de práctica de seguridad de los pacientes.METODOS: Se utilizaron 3 etapas (diagnóstico, creación de redes sociales privadas y públicas) como instrumento para promover una comunidad de práctica de seguridad de los pacientes.RESULTADOS: En una encuesta inicial, 227/235 personas (96%) aceptaron formar parte de la red. Primero se desarrolló una red privada, que incluyó miembros adicionales y tuvo 262 integrantes. Se postearon 11 recursos y se generaron 40 comentarios. Luego se pasó a la red pública y se realizaron 63 posteos (28 realizados por los usuarios). Se detectaron 104 "Me gusta" y 40 comentarios. Se inauguró la sección "charlando con...", publicada a través del canal institucional creado en YouTube. Se estableció una alianza formal con la red española "El observatorio para la seguridad de los pacientes".CONCLUSIONES: El uso de una red social para la seguridad de los pacientes permite la participación de los interesados y la difusión a gran escala del tema. La participación activa de sus miembros no pudo demostrarse con las estrategias tecnológicas ensayadas, por lo que deberán explorarse otras con distinto formato para evaluar su efectividad.

INTRODUCTION: The issue of patient safety has gained greater importance during the last years. Informatin and knowledge need to be systematized, translated and adapted to local contexts for a better use. Through its website, the National Academy of Medicine in Argentina has built a user network of more than 5.000 people. The site was developed with one-way communication approach aimed at health effectors, not at general public.OBJECTIVE: To develop a patient safety community of practice through social networks.METHODS: Three phases (diagnosis, creation of private and public networks) were used as instruments to promote a community of practice on patient safety.RESULTS: An initial survey was conducted, in which 227/235 people (96%) agreed to join the network. A private network was first developed with 262 member (after including additional ones), 11 appeals were posted and 40 comments were written. The public network detected 63 postings (28 made by users), 104 "Like" and 40 comments. The section "chatting with..." was opened through the institutional channel created in YouTube. A formal alliance was established with the Spanish network "El observatorio para la seguridad de los pacientes" (The safery patients Observatory).CONCLUSIONS: The use of a social network for patient safery allows the participation of stakeholders and the widespread dissemination of the issue. However, the technological strategies of this study could not demonstrate the active participation of its member. A different format must be explored and tested to evaluate the effectiveness.

Acceso a la información sobre seguridad del paciente: desarrollo de una plataforma para facilitar la gestión del conocimiento / Access to information on patient safety: development of a platform to facilitate knowledge management

INTRODUCCION: La seguridad del paciente ha cobrado mayor relevancia en los últimos años. La acumulación de información y conocimientos demanda la sistematización, traducción y adecuación a los contextos locales para obtener un mejor aprovechamiento. Desde su sitio web, la Academia Nacional de Medicina ha logrado construir una red de usuarios con más de 5.000 personas. El sitio fue desarrollado con un enfoque comunicacional unidireccional, dirigido a efectores de salud y no al público en general.OBJETIVO: Desarrollar a través de las redes sociales una comunidad de práctica de seguridad de los pacientes.METODOS: Se utilizaron 3 etapas (diagnóstico, creación de redes sociales privadas y públicas) como instrumento para promover una comunidad de práctica de seguridad de los pacientes.RESULTADOS: En una encuesta inicial, 227/235 personas (96%) aceptaron formar parte de la red. Primero se desarrolló una red privada, que incluyó miembros adicionales y tuvo 262 integrantes. Se postearon 11 recursos y se generaron 40 comentarios. Luego se pasó a la red pública y se realizaron 63 posteos (28 realizados por los usuarios). Se detectaron 104 "Me gusta" y 40 comentarios. Se inauguró la sección "charlando con...", publicada a través del canal institucional creado en YouTube. Se estableció una alianza formal con la red española "El observatorio para la seguridad de los pacientes".CONCLUSIONES: El uso de una red social para la seguridad de los pacientes permite la participación de los interesados y la difusión a gran escala del tema. La participación activa de sus miembros no pudo demostrarse con las estrategias tecnológicas ensayadas, por lo que deberán explorarse otras con distinto formato para evaluar su efectividad.

INTRODUCTION: The issue of patient safety has gained greater importance during the last years. Informatin and knowledge need to be systematized, translated and adapted to local contexts for a better use. Through its website, the National Academy of Medicine in Argentina has built a user network of more than 5.000 people. The site was developed with one-way communication approach aimed at health effectors, not at general public.OBJECTIVE: To develop a patient safety community of practice through social networks.METHODS: Three phases (diagnosis, creation of private and public networks) were used as instruments to promote a community of practice on patient safety.RESULTS: An initial survey was conducted, in which 227/235 people (96%) agreed to join the network. A private network was first developed with 262 member (after including additional ones), 11 appeals were posted and 40 comments were written. The public network detected 63 postings (28 made by users), 104 "Like" and 40 comments. The section "chatting with..." was opened through the institutional channel created in YouTube. A formal alliance was established with the Spanish network "El observatorio para la seguridad de los pacientes" (The safery patients Observatory).CONCLUSIONS: The use of a social network for patient safery allows the participation of stakeholders and the widespread dissemination of the issue. However, the technological strategies of this study could not demonstrate the active participation of its member. A different format must be explored and tested to evaluate the effectiveness.

Adherence to local guidelines for venous thromboprophylaxis: a cross-sectional study of medical inpatients in Argentina.

BACKGROUND: Venous thromboembolism prophylaxis has been shown to safely and cost-effectively reduce the incidence of thromboembolic events in medical inpatients. However, there is a gap between evidence and medical practice. The aim of this study was evaluate the appropriateness of prescribing venous thromboembolism prophylaxis in accordance with local recommendations for medical inpatients. METHODS: This cross-sectional study included 310 prescriptions of medical general-ward admitted patients of two university hospitals of Buenos Aires, Argentina.Data was collected using filled-out prescriptions, medical records and interviews with the head attending physician. Information was gathered at different times during 16 days randomly selected over September 2007 and January 2008. RESULTS: One hundred eighty eight patients' prescriptions (60.6%) were appropriate according to the institutional guidelines. Inappropriateness was due to excessive (14.2%), insufficient (15.8%) and absent (9.4%) prescribing. According to the recommendations of the American College of Chest Physicians, 256 (82.6%) patients received appropriate prophylaxis. Twenty-nine patients (9.4%) were considered at low risk for thromboembolism and did not need pharmacologic or mechanical prophylaxis. One hundred three patients (33.2%) had at least one major risk factor for venous thromboembolism. Compliance with the institutional guidelines was more frequently in the case of high risk patients. Complex preventive measures and low risk patients were related to lower adherence to recommendations. In the multivariate analysis, predictors of inappropriateness were the requirement of a surgical procedure and absence of prophylaxis prescribing at admission. In contrast, patients with a diagnosis of gastrointestinal disorders had lower odds of inappropriateness than those with an infectious disease. CONCLUSIONS: Most medical inpatients received some thromboprophylaxis measure, but the compliance with recommendations was less frequent. Efforts should be made to improve the appropriate prescription.

Hemoglobin concentration variations over time in general medical inpatients.

BACKGROUND: A decrease in hemoglobin concentration [Hb] with no apparent cause is frequently observed in critically ill patients. Scarce information is available about this situation in general ward-admitted patients (GWAP). OBJECTIVES: To describe [Hb] variation with no obvious cause in GWAP, and to estimate the prevalence and predictors of patients with [Hb] decreases > or =1.5 g/dL. DESIGN, SETTING AND PATIENTS: Prospective, observational study in internal medicine GWAP, carried out at two teaching hospitals in Buenos Aires, Argentina. Patients with a history of, or admitted for diseases associated with decreases in [Hb], as well as those with length of stay less than three days, were excluded. MEASUREMENTS: Upon hospitalization, complete personal and clinical data were recorded. Furthermore, Katz index, APACHE II acute physiology score (APS) and Charlson score were calculated. [Hb] and hematocrit (HCT) were also assessed during hospitalization. RESULTS: A total of 338 patients were evaluated, 131 were included. A mean [Hb] decrease of 0.71 g/dL was observed between admission and discharge (P < 0.001; 95% CI, 0.47-0.97). Forty-five percent of the included patients had decreases in [Hb] > or = 1.5 g/dL. This was associated with a higher APS, a higher [Hb] at admission, and a discharge diagnosis of infectious or gastrointestinal disease. No bleeding episodes were observed. CONCLUSIONS: An [Hb] decrease was frequently observed during GWAP hospitalization with no evident blood loss. Even though this decrease has multiple causes, the severity of the acute illness seems to play a major role.