[Validity of the protocol for evaluating the inappropriate use of hospitalization]. / Validez del protocolo de evaluación del uso inapropiado de la hospitalización.

BACKGROUND: The study was carried out in order to assess the inter-observer reliability and validity in respect of clinical appraisal given by the Appropriateness Evaluation Protocol (AEP), in the context of the Spanish Public Hospital System. MATERIAL AND METHOD: In order to assess the reliability a total of 614 hospital stays chosen at random from 56 hospital admissions were independently analysed by three reviewers (two doctors and one nurse). In order to assess the validity, the findings obtained by the nurse were compared with the majority opinion given by the 7 hospital specialists in respect of each of hospital stays under evaluation. As part of the analytical procedure, indices for observed agreement, and specific agreement were calculated, as well as the Kappa statistic, all forming of various random samples of 614 hospital stays. In order to assess the predictive validity of the AEP, its sensitivity, specificity and predictive values were all measured against the majority clinical judgement. RESULTS: The study exhibited a high degree of inter-observer reliability (specific agreement > 64%, kappa > 0.75) and a reasonable validity in comparison with the consensus of opinions formed by a least 4 or 5 of its 7 clinical reviewers (specific agreement > 61%, kappa > 0.64), these values decreasing notably when the consensus of 6 or 7 of the reviewers was required. The AEP revealed a high degree of sensitivity and a low degree of specificity in comparison with the majority clinical assessment, thus minimising the occurrence of false results when the stay was regarded as appropriate, and producing false negatives (appropriate hospital stays regarded as inappropriate) varying in degree from moderate to very high. CONCLUSIONS: The results showing high reliability and moderate validity regarding clinical assessment shows the AEP to be a useful instrument in the sifting-out of inappropriate use of hospitalisation, although they do not allow a definitive judgement to be made concerning the efficiency of hospital services nor judgements regarding individual cases.

[Venous reservoirs: the late complications according to the route of implantation. The Interhospital Group of Valencia (GIHV)]. / Reservorios venosos: complicaciones tardías según la vía de implantación. Grupo Interhospitalario Valenciano (GIHV).

UNLABELLED: The aim of the study which we present is to analyze the incidence of late complications, clinical and sub-clinical, of venous reservoirs implanted through two access routes, subclavian (group A), and brachial (group B). It is a multi-centric clinical study, initiated in 1992, in which the general surgery departments of three general hospitals of the Valencian Community were involved. It is made up of 87 patients, 48 men and 39 women, with a mean age (SD) of 57.1 (12.6) years, of whom we made a late review of 41 patients (29 from group A and 12 from group B). They were subjected to a physical examination, bacterial cultures of the entrance, and phlebograms of the upper extremities through the dorsal veins of the hands. RESULTS: The incidence of clinical complications was 39% in group A and 77% in group B (p = 0.0507). The main clinical complications were minimally symptomatic venous thrombosis, catheter thrombosis, infection, and miscellaneous (migration, paresthesias, articular movement alterations, etc.). And the prevalence of phlebographic venous thrombosis was 18% in group A and 40% in group B (p = 0.051). CONCLUSIONS: The subclavian access for the implantation of venous reservoirs has a lower incidence (with a tendency towards clinical significance) of clinical complications and subclinical venous thrombosis (Phlebogram) than the brachial access.

[Streptococcus bovis in a surgical wound and a colonic neoplasm]. / Streptococcus bovis en herida quirúrgica y neoplasia de colon.

The association of colorectal carcinoma and septicemia or endocarditis by Streptococcus bovis is well known. Nonetheless, other localizations of infection by Streptococcus bovis have not been associated with colorectal carcinoma. The case of association of colon neoplasm with infection by Streptococcus bovis localized in the surgical wound of resection of a prostate adenoma by the transvesical route carried out four months previously is presented. Possible intraoperative bacteremia colonizing the surgical wound due to colic compression during surgery may have been the cause. This localization of infection by Streptococcus bovis should be taken into account in screening of colorectal carcinoma.

[Subcutaneous injection chambers for central venous access: a multicenter clinical trial. The Interhospital Group of Valencia (GIHV)]. / Cámaras de inyección subcutánea para acceso venoso central: un ensayo clínico multicéntrico. Grupo Interhospitalario Valenciano (GIHV).

UNLABELLED: A multicentric clinical trial was performed to evaluate two routes of access for implantable subcutaneous central venous devices: by way of the subclavian vein (group A) and peripheral access by way of the veins of the flexion side of the elbow (group B). The indications for implantation were: antineoplastic treatment of solid tumors, myelo- and lymphoproliferative syndromes, antiviral treatment, and parenteral nutrition at home. The study was composed of 87 patients, 48 men and 39 women, with a mean age of 57.1 years (SD = 12.6). Group A was made up of 48 patients, and group B of 39. RESULTS: Implantation failure was 8.3% in group A and 5.1% in group B (p = n.s.). Complications of implantation were 23.4% in group A and 15.4% in group B (p = n.s.). The complications of permanence were diagnosed at 27.6% in group A and at 15.4% in group B (p = n.s.). CONCLUSIONS: We have not been able to find significant differences between the two groups, probably due to the fact that the series is still short. Nevertheless, the manageability, comfort for the nursing staff and for the patients, appears to be greater with the devices implanted in the infraclavicular region, by means of a subclavian vein puncture.

How many days of hospitalization for an appendectomy?

The length of stay (LOS) of a surgical procedure is influenced both by the real need for medical and nursing care of the patient and also by the practice style of each unit, which can include unjustified stays. The aim of this work was to estimate the appropriate LOS for appendectomy and its differences with the LOS observed in practice. Two hundred and forty-nine medical records (249 admission days and 1447 successive stays) for patients over 6 years old who had had an appendectomy in 1992 were classified by Diagnosis Related Groups (DRG) and reviewed using the Appropriateness Evaluation Protocol. 1.6% of admission days and 31.7% of successive stays were assessed inappropriate. The appropriate LOS for appendectomy was 4.7 days as opposed to 6.8 days of observed LOS. For the DRG 167 (76.3% of the sample) appropriate LOS was 3.4 days (observed LOS 4.9 days). These results suggest the existence of an important proportion of avoidable hospital stays and provides a simple and low cost methodology for assessing the suitability of local hospitalization practices.

The impact of low-residue enteral feeding on the healing of colonic anastomoses.

This study was carried out with the aim of comparing colonic anastomosis cicatrization in rats fed either standard rat chow or a low-residue enteral diet. Energy intake, the evolution of body weight, fecal weight, macroscopic and microscopic evaluation of the anastomoses, anastomotic bursting pressure, and collagen concentration in the anastomotic tissue were all evaluated. Anastomotic complications were more common among the animals fed standard rat chow, and cicatrization was more inflammatory than in the rats given a low-residue enteral diet. Although the latter was more effective in preventing anastomotic complications, it resulted in a lower gain in collagen and hence a diminished resistance to the increase in intraluminal pressure associated with the administration of such diets. Colonic contents, including the fecal bolus and bacteria, may be held responsible for the increased number of complications, the augmentation of collagen content, and the improvement in the resistance to intraluminal pressure.

[Low-residue diets supplemented with fermentable fiber. Effect on experimental colonic anastomosis]. / Dietas de bajo residuo suplementadas con fibra fermentable. Efecto sobre las anastomosis cólicas experimentales.

Presentation of an experimental study comparing the scarring of colic anastomoses performed in Wistar rats fed with three different types of diet: a standard laboratory diet, an enteral low-residue diet and a low-residue diet supplemented with fermentable fibre in short chain fatty acids (pectin). Scarring in the group fed with the standard laboratory diet showed greater anastomotic complications, and the microscopic appearance was more inflamed. The administration of low-residue diets reduced the level of complications, but also reduced the concentration of collagen and the parietal rupture tension. The addition of pectin to a low-residue diet maintained the complications at a low level, and also significantly increased the pressure parameters and the collagen concentration.