Bajo rendimiento del ecocardiograma, comparado con el Doppler transcraneal, en la detección de la comunicación derecha-izquierda / Low sensitivity of the echocardiograph compared with contrast transcranial doppler in right-to-left shunt

Introducción: El Doppler transcraneal con contraste (DTC-c) tiene una alta sensibilidad para la detección de comunicación derecha-izquierda (CDI), probablemente mayor que la del ecocardiograma transtorácico (ETT) y comparable con la del transesofágico (ETE). Objetivo: Evaluar la precisión del ecocardiograma (ETT y ETE) para detectar CDI, comparándolo con DTC-c. Material y métodos: Estudio observacional de pacientes <55 años con isquemia cerebral de origen indeterminado (2007-2009) a los que se les realizó una monitorización con DTC-c para detectar CDI, en reposo y tras maniobra de Valsalva (MV). El ETT y ETE se realizaron cuando estaba indicado según el protocolo de estudio cerebrovascular de nuestro centro. La precisión del ETT y ETE para detectar CDI fue calculada comparándolos con DTC-c. Resultados: Se incluyeron 115 pacientes a los que se les realizó monitorización con DTC-c. Edad media 43,3 (DE 10,3) años, 51,3% hombres. El ETT se realizó en 102 y el ETE en 81 pacientes. La detección de CDI fue mayor con DTC-c que con ETT (67,6 vs. 22,5%, p=0,001) o con ETE (77,8 vs. 53,1%, p=0,001). El ETT, comparado con DTC-c tras MV, mostró: sensibilidad 31,8%, especificidad 96,9%, valor predictivo positivo (VPP) 95,6%, valor predictivo negativo (VPN) 40,5% y precisión 52.9% para detectar CDI. El ETE, comparado con DTC-c tras MV, mostró: sensibilidad 63,4%, especificidad 83,3%, VPP 93%, VPN 39,4% y precisión 67,9%. La precisión del ETT y ETE se incrementó cuando se compararon con el DTC-c en reposo. Conclusiones: El ETT y ETE presentan un número elevado de falsos negativos para detección de CDI, cuando se comparan con el DTC-c. Los estudios clínicos deberían considerar al DTC-c como mejor técnica para diagnosticar CDI cuando se sospecha embolia paradójica (AU)

Background: Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE).Objective: To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD.Material and methods: Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD. Results: A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest. Conclusions: TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected (AU)

[Low sensitivity of the echocardiograph compared with contrast transcranial Doppler in right-to-left shunt]. / Bajo rendimiento del ecocardiograma, comparado con el Doppler transcraneal, en la detección de la comunicación derecha-izquierda.

BACKGROUND: Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE). OBJECTIVE: To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD. MATERIAL AND METHODS: Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD. RESULTS: A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest. CONCLUSIONS: TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected.

[Development of an acute stroke care pathway in a hospital with stroke unit]. / Implantación de una vía clínica para la atención del ictus agudo en un hospital con unidad de ictus.

INTRODUCTION: Care pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU). METHODS: Members of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides. RESULTS: The following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document. CONCLUSIONS: A stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction.

Implantación de una vía clínica para la atención del ictus agudo en un hospital con unidad de ictus / Development of an acute stroke care pathway in a hospital with stroke unit

Introducción: Las vías clínicas (VC) son herramientas para la asistencia estandarizada en procesos con poca variabilidad que se han demostrado útiles en la práctica clínica. Se han realizado varias VC de ictus en servicios de medicina general, rehabilitación y salas de neurología, pero no así en hospitales con unidad de ictus agudo. El objetivo es desarrollar una VC capaz de organizar y homogeneizar la atención integrando los estándares de calidad en un hospital universitario con una unidad de ictus agudo (UI). Métodos: Miembros de los servicios de Neurología, Rehabilitación, Urgencias y Medicina Preventiva del Hospital Universitario La Paz establecieron un programa de nueve reuniones quincenales. En éstas se elaboraron los diversos documentos que integran la VC siguiendo el modelo FOCUS-PDCA, de acuerdo con la evidencia científica y las guías clínicas vigentes. Resultados: Los documentos resultantes son: matriz temporal científico-técnica que integra todos los procesos; documento de información al ingreso para pacientes y familiares; protocolos de enfermería (riesgo social, disfagia, caídas y úlceras por presión); pautas de actuación en la rehabilitación del ictus para el personal sanitario; órdenes de tratamiento y cuidados; hoja de información al alta para pacientes y familiares; documento de información de rehabilitación para pacientes y familiares; unidades didácticas específicas; encuesta de satisfacción de la atención recibida para pacientes y familiares, y estándares de calidad. Conclusiones: El desarrollo de una VC de ictus en un hospital con UI tiene el potencial de promover un cuidado organizado y eficiente del paciente, así como mejorar la satisfacción de éste por la atención recibida (AU)

Introduction: Care pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU). Methods: Members of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides. Results: The following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document. Conclusions: A stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction (AU)