Hallazgo Incidental de Tumor Estromal Gastrointestinal en Divertículo de Meckel. Caso Clínico

Introducción: El divertículo de Meckel es un defecto sacular ubicado en el íleon distal, con una tasa de complicaciones de 4%. La resección quirúrgica está indicada en estas complicaciones, siendo controversial en casos asintomáticos o incidentales. Dentro de las complicaciones existen tumores como los estromales gastrointestinales (GIST). Caso Clínico: Hombre de 57 años, postrado por múltiples factores, presenta úlcera por presión sacra grado IV sobreinfectada y con evolución tórpida. Se decide realizar colostomía terminal, evidenciando un divertículo de Meckel en el intraoperatorio con aspecto sospechoso, por lo cual se decide resecar, resultando en un GIST de bajo riesgo. Se mantiene en seguimiento por 6 meses, sin recidiva tumoral. Discusión: Mientras que la cirugía pareciera ser imperativa en complicaciones, aún existe debate respecto a las indicaciones de resección de divertículo de Meckel hallado incidentalmente en el intraoperatorio por cirugía de otra causa. Si bien puede aumentar la morbimortalidad, la resección estaría indicada según ciertas características como edad, sexo, tamaño y aspecto, dado el riesgo de desarrollo de complicaciones y neoplasias.

Introduction: Meckel's diverticulum is a saccular defect located in the distal ileum, with a complication rate of 4%. Surgical resection is indicated when these complications occur, yet resection in asymptomatic or incidental cases remains controversial. Among these complications, the appearance of tumors such as gastrointestinal stromal (GIST), may occur. Case Report: A 57-year-old male, bedridden due to multi- ple factors, presents with a complicated grade IV sacral pressure ulcer with a torpid evolution. An end colostomy is performed, evidencing a suspicious-looking Meckel's diverticulum intraoperatively, which was resected and resulted to be a low-risk GIST. At a 6-month follow-up, the patient showed no evidence of tumor recurrence. Discussion: While surgery seems to be imperative in complications, there is still a debate regarding the indications for resection of Meckel's diverticulum found incidentally intraoperatively due to surgery for another cause. Although it could increase morbidity and mortality, resection could be indicated according to certain characteristics such as age, sex, size and appearance, given the risk of developing complications and neoplasm.

Reconstrucción microquirúrgica en pandemia por Covid-19 / MICROSURGICAL RECONSTRUCTION IN THE COVID - 19 PANDEMIC

Introducción: la Pandemia por SARS CoV ­ 2 (COVID ­ 19) tuvo un impacto significativo en el desarrollo de los servicios quirúrgicos en general y obligo a establecer protocolos de actuación para las distintas patologías a fin de cuidar al máximo los recursos humanos y la capacidad instalada de los hospitales para hacer frente a esta contingencia mundial. Objetivos: presentar una casuística de 7 pacientes con reconstrucción microquirúrgica de patología de cabeza y cuello en estadios avanzados y patología de miembros inferiores durante la pandemia por COVID - 19. Materiales y Métodos: trabajo retrospectivo, se revisaron las historias clínicas físicas y digitales. Se incluyeron 5 pacientes con patología avanzada de cabeza y cuello y 2 pacientes con patología de miembros inferiores. Resultados: cinco pacientes fueron operados por patología avanzada de cabeza y cuello: 3 pacientes con carcinomas escamosos de cavidad oral estadio IVa, 1 paciente con carcinoma escamoso de piel avanzado estadio IV y 1 paciente con fractura compleja de maxilar inferior por herida de arma de fuego con fistula oro-cutánea crónica, con exposición del material de osteosíntesis, mala oclusión y pérdida de peso importante por dificultad para alimentación. Dos pacientes fueron operados por patología de miembros inferiores en tercio inferior de pierna, uno por fractura expuesta grave con defecto de tejidos blandos y el otro por una ulcera arterial. Conclusión: la cirugía reconstructiva microquirúrgica puede realizarse con buenos niveles de seguridad para el personal de salud y para los pacientes afectados por patologías avanzadas de cabeza y cuello y otras patologías que requieran colgajos libres. Es fundamental respetar estrictamente los protocolos para evitar los contagios en el medio intrahospitalario, entendiendo que debe considerarse todo paciente que ingrese al hospital como COVID (+) hasta que se demuestre lo contrario

Introduction: the SARS CoV ­ 2 (COVID ­ 19) Pandemic had a significant impact on the development of surgical services in general and forced the establishment of action protocols for the different pathologies in order to take maximum care of human resources and capacity. installed in hospitals to deal with this global contingency. Objectives: to present a casuistry of 7 patients with microsurgical reconstruction of head and neck pathology in advanced stages and lower limb pathology during the COVID - 19 pandemic. Materials and Methods: retrospective work, physical and digital medical records were reviewed. Five patients with advanced head and neck disease and 2 patients with lower limb disease were included. Results: five patients underwent surgery for advanced head and neck disease: 3 patients with stage IVa squamous cell carcinoma of the oral cavity, 1 patient with stage IV advanced squamous cell carcinoma of the skin, and 1 patient with a complex fracture of the lower jaw due to a gunshot wound. with chronic oro-cutaneous fistula, with exposure of the osteosynthesis material, poor occlusion and significant weight loss due to difficulty feeding. Two patients underwent surgery for pathology of the lower limbs in the lower third of the leg, one for a severe open fracture with a soft tissue defect and the other for an arterial ulcer. Conclusion: microsurgical reconstructive surgery can be performed with good levels of safety for health personnel and for patients affected by advanced pathologies of the head and neck and other pathologies that require free flaps. It is essential to strictly respect the protocols to avoid contagion in the hospital environment, understanding that every patient who enters the hospital must be considered as COVID (+) until proven otherwise.

Apendicectomía profiláctica en la dotación Antártica: experiencia del Hospital de la Fuerza Aérea de Chile / Prophylactic appendectomy in the Antarctic endowment: experience of the Chilean Air Force Hospital

Resumen Objetivo: Reportar y caracterizar las complicaciones quirúrgicas de las apendicectomías laparoscópicas electivas profilácticas, realizadas a pacientes destinados a dotación antártica, realizadas en Hospital clínico de la Fuerza Aérea de Chile (FACh). Materiales y Método: Análisis retrospectivo descriptivo de fichas clínicas de todos los pacientes sometidos a apendicectomía laparoscópica profiláctica entre los años 2013 y 2017 en Hospital FACh. Se registraron variables demográficas y quirúrgicas de los pacientes. Las complicaciones fueron registradas y clasificadas de acuerdo a Clavien-Dindo. Resultados: Se incluyeron 200 pacientes, 96% hombres y solo 4% mujeres. Se registraron 6 pacientes (3%) con complicaciones quirúrgicas, clasificadas como grado I según Clavien-Dindo. Discusión: No existen reportes de complicaciones en apendicectomías profilácticas. En nuestra serie éstas alcanzan el 3%. Conclusiones: La apendicectomía profiláctica es una cirugía segura, con escasas complicaciones, pero existen y se desarrollan en un paciente que estaba previamente sano.

Aim: To present and characterize surgical complications of elective prophylactic appendectomies, performed in patients for the Antarctic endowment at the Hospital Clínico de la Fuerza Aérea de Chile. Materials and Method: Retrospective descriptive analysis of all patients operated of prophylactic laparoscopic appendectomy between 2013 and 2017. Demographic and surgical variables of the patients were recorded and analysed. Complications were classified according Clavien-Dindo. Results: 200 patients were included, 96% mens. Six patients (3%) had a surgical complication, all classified as Grade I. Discussion: There are no previous reports of surgical complications on prophylactics appendectomies. The complications rate is 3%. Conclusions: The prophylactic appendectomy is a safe surgery with a low rate of complications, although its exists and develops in a previously healthy patient.

Páncreas ectópico, diagnóstico diferencial de lesión gástrica subepitelial: reporte de caso y enfrentamiento inicial / Ectopic pancreas, differential diagnosis of subepithelial gastric lesion: case report and initial confrontation

Subepithelial lesions are generally an incidental diagnosis with an prevalence of 0.4%. These tumors represent a great diagnostic challenge, mainly when ruling out potentially malignant lesions, such as gastrointestinal stromal tumor (GIST), lymphomas and carcinomas. Among the many differential diagnosis, the ectopic pancreas arises with an prevalence of 1-2% in general population. The first diagnostic approach is performed using upper digestive endoscopy, computed tomography and endosonography. This last one has a diagnostic performance of less than 50%, which increases to 90% when it is associated with a histopathological examination. There is no current consensus regarding the management and monitoring of these lesions. Based on the imaging and histological characteristics, the possibilities range from observation to endoscopic or surgical resection. In this context, we will present a clinical case of ectopic pancreas as an incidental finding, and afterwards the diagnostic and therapeutic breakdown of subepithelial lesions.

Las lesiones subepiteliales son pesquisadas generalmente de manera incidental, con una prevalencia de 0,4%. Estos tumores suponen un gran desafío diagnóstico, principalmente al momento de descartar lesiones potencialmente malignas, como el tumor estromal gastrointestinal (GIST), linfomas y carcinomas. Dentro de los posibles diagnósticos, surge el páncreas ectópico, con una prevalencia de hasta 1-2% en la población general. La primera aproximación diagnóstica se realiza mediante endoscopia digestiva alta, tomografía computarizada y la endosonografía, ésta última con un rendimiento diagnóstico menor del 50%, que aumenta hasta el 90% al asociar el examen histopatológico. No existe consenso actual respecto al manejo y seguimiento de estas lesiones, que según sus características imagenológicas e histológicas, va desde la observación hasta la resección endoscópica o quirúrgica. En este contexto, se presenta un caso clínico de páncreas ectópico como hallazgo incidental y el desglose diagnóstico y terapéutico de las lesiones subepiteliales.

Insuficiencia suprarenal secundaria al uso de corticoides inhalados: reporte de caso / Adrenal insufficiency secondary to use of inhaled corticosteroids: case report

La insuficiencia suprarrenal es un síndrome que se produce por la disminución de niveles séricos de glucocorticoides, la cual se clasifica en primaria o secundaria, según la etiología. El uso prolongado de corticoides exógenos a altas dosis puede producir una inhibición en el eje hipotálamo-hipofisiario-adrenal, y la supresión aguda de éstos produce insuficiencia suprarrenal secundaria. Los glucocorticoides inhalados, usados ampliamente como tratamiento del asma bronquial, pudiesen tener un impacto a nivel del eje adrenal, principalmente en la población pediátrica. Por el momento, si bien hay reportes de casos que evidencian insuficiencia suprarrenal secundaria al uso de corticoides tanto tópicos como inhalatorios, aún es materia de discusión esta interacción a nivel sistémico, con artículos que se contraponen en sus resultados. Se presenta un caso clínico de una paciente usuaria de glucocorticoides inhalatorios por el antecedente de asma bronquial, que desarrolla una clínica de insuficiencia suprarrenal en el periodo de lactancia.

Adrenal insufficiency is a syndrome that is produced by the decrease in serum glucocorticoid levels, which is classified as primary or secondary, according to the etiology. Prolonged use of exogenous corticosteroids at high doses may cause inhibition in the hypothalamic-pituitary-adrenal axis, and acute suppression of these results in secondary adrenal insufficiency. Inhaled glucocorticoids, widely used as a treatment for bronchial asthma, could have an impact at the level of the adrenal axis, mainly in the pediatric population. At the moment, although there are reports of cases that show adrenal insufficiency secondary to the use of both topical and inhalation corticosteroids, this interaction at systemic level is still a matter of discussion, with articles that contrast in their results. We present a clinical case of a patient using inhaled glucocorticoids due to a history of bronchial asthma, which develops a clinical of adrenal insufficiency in the period of breastfeeding.

The role of angiogenic biomarkers and uterine artery Doppler in pregnant women with systemic lupus erythematosus or antiphospholipid syndrome.

OBJECTIVE: To evaluate the usefulness of the uterine artery mean pulsatility index (mPI-UtA) and the sFlt-1/PlGF ratio in women with systemic lupus erythematosus (SLE) or antiphospholipid syndrome (APS) for the prediction of placental dysfunction-related adverse outcomes (AO), namely pre-eclampsia (PE) and intrauterine growth restriction (IUGR), and for differential diagnosis between PE and SLE flares. STUDY DESIGN: Observational prospective cohort study of 57 pregnant women with SLE or APS. MAIN OUTCOME MEASURES: mPI-UtA and sFlt-1/PlGF ratio in maternal serum were obtained at four gestational age periods (11-14, 19-22, 24-29 and 32-34 weeks). Comparisons among pregnancies with normal outcome, SLE flare and AO were performed. RESULTS: Overall, we had 44 ongoing pregnancies (36 with SLE and 8 with APS) of which most (n = 35, 80%) were uncomplicated. The overall rate of AO was 9% (n = 4), that was diagnosed at a mean (SD) gestational age of 34.1 (7.5) weeks. Five SLE patients (14%) suffered a SLE flare. No differences for these markers were found between normal pregnancies and those affected by SLE flare. mUtA-PI values were significantly higher in the AO group when compared with normal and SLE flare groups, at 19-22 weeks (1.52, 0.95 and 0.76) and 32-34 weeks (1.13, 0.68 and 0.65), respectively. The sFlt-1/PlGF ratio was significantly higher in the AO group at 24-29 weeks (191.1, 3.1 and 9.2), respectively. CONCLUSION: Our preliminary results indicate that mPI-UtA and sFlt1/PlGF ratio may be useful to predict AO in women with SLE, and to make the differential diagnosis with a lupus flare.

Familial hypobetalipoproteinemia: analysis of three Spanish cases with two new mutations in the APOB gene.

Extremely low LDL-cholesterol concentrations are very unusual and generally related with comorbidities accompanying malnutrition. Less frequently low LDL-cholesterol levels result from mutations in the APOB, PCSK9, ANGPTL3, SAR1B and MTTP genes (primary hypobetalipoproteinemia). We investigated three patients with plasma LDL-cholesterol levels below the fifth percentile of the Spanish population. We recorded data on demographic and anthropometric characteristics, life style habits, physical examination, liver ultrasound and lipid and lipoprotein levels, in the probands and their first-degree relatives. Secondary causes of hypocholesterolemia were ruled out by clinical study, complementary tests and follow-up. The APOB, MTTP and SAR1B genes were sequenced. Patients were found to be heterozygotes for point mutations located in the exon 26 of the APOB gene. One patient, with fatty liver, carried a previously described mutation (c.7600C>T) (Arg2507X), causing the formation of truncated Apo B-55.25. The other two mutations producing truncations are new. One asymptomatic patient carried the Arg3672X (Apo B-80.93) and the other with fatty liver and steatorrhea carried the Ser2184fsVal2193X (Apo B-48.32). Our study reinforces the concept that in the heterozygous carriers of truncated Apo Bs, the clinical manifestations of FHBL are dependent on the size of the truncations.

Parametros testiculares y caracteristicas morfologicas de los espermatozoides epididimarios obtenidos postmortem en el toro de lidia / Testicular parameters and morphological characteristic of epididymal spermatozoids collected postmortem in the bullfight

En el presente trabajo se han evaluado determinados parámetros testiculares y características morfológicas de los espermatozoides epididimarios obtenidos postmortem en el toro de lidia, teniendo en cuenta la edad, el peso del animal, la circunferencia escrotal, peso y longitud testicular, y sus variables espermáticas. Se analizaron 12 pares de testículos de toros lidiados en una Plaza de Toros, procedentes de doce astados encaste Domecq de dos ganaderías. Una vez llegado el toro al desolladero de la plaza, se midió la circunferencia escrotal, se extrajeron los testículos y se conservaron a una temperatura de 5ºC, previamente identificados. Posteriormente en laboratorio se realizó el pesaje y medición de cada testículo, se diseccionó la cola del epidídimo para conseguir la muestra. Se midió volumen, concentración espermática, motilidad. Por último se realizaron extensiones con la tinción de eosina nigrosina y se valoraron espermatozoides vivos y muertos, células normales, células anormales y acrosomas normales. La muestra obtenida de cada testículo, fue diluida en una proporción 1:2 con un diluyente comercial (Steridyl®), ambos atemperados a 37ºC, antes de realizar las tinciones y las extensiones. Con el fin de estudiar las características espermáticas y los parámetros testiculares de toros de lidia provenientes de dos ganaderías, se realizó un diseño completamente al azar con un arreglo factorial 2x2 (dos ganaderías y dos testículos). Los resultados muestran que hay diferencias significativas (p<0,05), de peso testicular entre la ganadería 1 de 467,33±17,89 y la ganadería 2 de 500,33±16,23. Para la variable circunferencia escrotal existen diferencias significativas (p<0,01) entre la ganadería 1 de 33,5±0,55 y la ganadería 2 de 36,5±1,52; encontrándose la misma diferencia significativa para el peso del testículo derecho e izquierdo, entre la primera ganadería de 295±4,56 y 293,5±4,41, y la segunda de 323,17±14,61 y 321,12±14,93 respectivamente. Para las demás variables evaluadas, concentracíón espermática, la motilidad individual, vivos y muertos, morfoanomalías y acrosomas normales, no se encontraron diferencias estadísticamente significativas (p<0,05). En general, se encontró que en las variables que hubo diferencias estadísticamente significativas, siempre se presentaba entre ganaderías y no tuvo que ver nada el efecto testículo (AU)

In the present work has been evaluated testicular parameters and morphological characteristic different of epididymal spermatozoids collected postmortem in the bullfight as age and weigh animal, scrotal circumference, weigh and long testicular and spermatic variables. Twelve both testicles of bullfight coming from two farms of Domecq has been analyzed. After arrived of bullfight to slaughterhouse the scrotal circumference was measured and the testicles extracted and preserved to 5º C of temperature after yours identification. Afterwards the weigh and measures of each testicle was realized in the laboratory. The epididymal tail was dissectioned for to collect the sample. The spermatic volume and concentration and motility were measured. For last extension of eosin-nigrosin stamp were realized and life and dead spermatozoids, usual and unusual cells and usual acrosomes were determined. Before to stamp, the sample collected of each testicle was diluted 1:2 proportion with commercial diluted (Steridyl®) both moderating to 37oC. In order to study the sperm characteristics and testicular parameters of bullfighting coming from two farms, was a completely random arrangement design 2 x 2 factorial (two farms and two testes). The results show that there are significant differences (p < 0,05), testicular weight between livestock 1 of 467,33±17,89 and livestock 2 of 500,33±16,23. For variable scrotal circumference, there are significant differences (p < 0.01) between livestock 1 of 33, 5±0, 55 and livestock 36,5±1,52; finding the same significant difference for the weight of the right and left testicle between the first breeding of 295±4, 56, 293, 5±4, 41, and the second in 323, 17±14, 61 and 321, 12±14, 93 respectively. For the other variables evaluated, sperm concentration, individual motility, alive and dead, morfoanomalias and normal acrosomas, no statistically significant differences were found (p < 0,05). In general, it was found that in the variables that were statistically significant differences, always presented between farms and did not nothing to the testicle effect (AU)

Percepción de la población respecto a los riesgos asociados a los estudios de imágenes / Public perception of radiation-related risks of imaging studies

Introduction: In recent years, diagnostic procedures using ionizing radiation have achieved a great boom, although patients are often unaware of the risks they involve. Objectives: To know how is ionizing radiation perceived by the population attending Clínica Dávila, Department of Radiology (DRCD).Methods: A voluntary and anonymous survey was conducted on patients and / or companions. Results: A total of 330 adults were surveyed. An 57 percent had completed higher education, whereas 7.9 percent had only finished elementary schooling; 78.8 percent had undergone three or more imaging tests. CT examination was considered to pose the highest levels of risk (42.4 percent), followed by Ultrasonography (30.6 percent). Discussion: The survey group was made up of young adults, mostly college graduates, and predominantly female. Surprinsingly enough, considering that obstetric sonography is commonly used during pregnancy, US was ranked second in terms of associated health risks. There is an evident interest in the subject, since 90 percent of responders would like to receive further information.

Introducción: Los procedimientos diagnósticos que usan radiación ionizante están en auge, aunque conllevan riesgos muchas veces desconocidos por los pacientes. Objetivos: Conocer la percepción de la población que acude al Departamento de Radiología de Clínica Dávila (DRCD) sobre la radiación. Material y métodos: Se aplicó una encuesta voluntaria y anónima a pacientes y/o acompañantes. Resultados: Se encuestó a 330 adultos. El 57 por ciento poseía estudios superiores y 7,9 por ciento sólo estudios básicos. El 78,8 por ciento se había efectuado 3 o más estudios radiológicos. La TC fue el examen considerado con mayor riesgo (42,4 por ciento), luego la US (30,6 por ciento). Discusión: El grupo encuestado fueron adultos jóvenes, con estudios superiores en su mayoría y con predominio femenino. Sorprendió que la US se considerara como el segundo examen de mayor riesgo, ya que las mujeres poseen mayor contacto con este estudio durante el embarazo. Hay interés en el tema, porque el 90 por ciento desea recibir información.

Protocolo de sincronización de celo en vacas de lidia con monta natural / Effective estrus synchronization protocol for fight cows undergo natural mount

La reproducción en la ganadería de lidia se encuentra condicionada por una serie de factores que pueden afectar tanto al semental como a las vacas de vientre, entre los que se pueden destacar el estrés derivado del manejo, la sanidad, el hábitat y la alimentación, así como la selección a la que han sido sometidos los progenitores. Es por esto que diferentes técnicas reproductivas que se aplican en otros bovinos no dan buenos resultados y provocan que el ganadero de bravo descarte su utilización. El objetivo de este estudio es obtener un protocolo de sincronización del celo válido para una ganadería de lidia con monta natural, para planificar la paridera. El estudio que llevamos a cabo se realizó en 20 vacas de la raza de lidia de diferentes edades y 1 semental de 8 años ya utilizado con anterioridad, que formaban un lote de reproductores de una explotación de lidia de la zona centro. Se empleó con las vacas un protocolo de sincronización de celo en dos manejos. Inicialmente se utiliza una esponja intravaginal de progestágeno y a los 8 días se inyecta por vía intramuscular gonadotropina coriónica equina y prostaglandina F2alfa, introduciendo entonces al animal sincronizado al cercado con el semental para monta natural. La sincronización y posterior introducción al cercado de monta se realizó de modo gradual con 4 vacas en cada grupo de sincronización. Los resultados obtenidos fueron positivos, con un incremento de la fertilidad en el conjunto de animales sincronizados hasta un 85%(AU)

Reproduction in fightingbull farm is conditioned by some factors that affect the stud and the cattle, where it emphasizes the stress derived of the using, the health, the environment and the food, just as the selection that have been subjected breeding. It means that different breeding techniques put into practice in other bovines don’t give good results and cause that bullfight farmer discard the use. The objective of this study is to obtain a estrus synchronization protocol valid for a bullfight farm with natural mount, to plan the births. This study was made in 20 bullfight cows with different ages and 1 eight years old stud used before, that formed one breeding lot in a bullfight farm of de centre zone. A estrus synchronization protocol in two steps was used. Firstly it was put progestin sponge in the vagina for 8 days and it was inyected intramuscular equine chorionic gonadotropine and F2alpha prostaglandine with cow, introducing then the synchronized animal in the enclosure with the stud, to the natural mount. The synchronization and the introduction to the enclosure were made gradual, with 4 cattle in each synchronization group. The results obtained were positive, with an increase of the fertility in the group of synchronized animals up to the 85%(AU)

Listeriosis durante el embarazo: importancia del tratamiento precoz / Listeriosis during pregnancy: Importance of early treatment

La infección por listeria monocytogenes durante la gestación tiene una repercusión grave en la evolución del embarazo.Ante una sospecha clínica, resulta indispensable iniciar un tratamiento precoz con ampicilina y gentamicina para evitar la infección neonatal secundaria a la bacteriemia materna.Describimos tres casos clínicos de listeriosis durante la gestación con distintos desenlaces en función de la precocidad del tratamiento (AU)

Listeria monocytogenes infection in pregnant women may have severe consequences for pregnancy outcome. Early antenatal treatment with ampicillin and gentamicin when there is clinical suspicion is highly recommended to avoid neonatal infection caused by maternal bacteremia. We describe three cases with distinct outcomes due to the different timing of treatment (AU)

Quality requirements for cross-border care in Europe: a qualitative study of patients', professionals' and healthcare financiers' views.

BACKGROUND: In the past decade the issue of patient mobility has emerged on the European health policy agenda. Although the volume of patients crossing borders to obtain healthcare is low, it is increasing continuously and, due to its legal, financial and medical implications, has generated considerable interest among health policy and other decision makers. However, there is little information available on the safety and patient-centredness of cross-border care and neither governments nor citizens have an explicit basis for comparing healthcare delivery in Europe. METHODS: This study investigated the viewpoints of patients, professionals and healthcare financiers on the safety and patient-centredness of cross-border care. Qualitative interviews were carried out during 2005 and early 2006 with 40 patients, 30 professionals (doctors, nurses and managers) and 3 healthcare-financing bodies. RESULTS: Although cross-border care has become a common issue in many European countries, there remain uncertainties on the side of each of the parties addressed--patients, professionals and financiers--with regard to the provision of cross-border care. One of the most striking results of this project is the current lack of research on systematic knowledge on the quality of cross-border care. CONCLUSION: Many of the issues identified through this research may have a potential impact on the quality and safety of cross-border care and will support further investigation and help shape the health policy agenda on patients crossing borders in European Union countries.

Application of quality improvement strategies in 389 European hospitals: results of the MARQuIS project.

CONTEXT: This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project investigating the impact of quality improvement strategies on hospital care in various countries of the European Union (EU), in relation to specific needs of cross-border patients. AIM: This paper describes how EU hospitals have applied seven quality improvement strategies previously defined by the MARQuIS study: organisational quality management programmes; systems for obtaining patients' views; patient safety systems; audit and internal assessment of clinical standards; clinical and practice guidelines; performance indicators; and external assessment. METHODS: A web-based questionnaire was used to survey acute care hospitals in eight EU countries. The reported findings were later validated via on-site survey and site visits in a sample of the participating hospitals. Data collection took place from April to August 2006. RESULTS: 389 hospitals participated in the survey; response rates varied per country. All seven quality improvement strategies were widely used in European countries. Activities related to external assessment were the most broadly applied across Europe, and activities related to patient involvement were the least widely implemented. No one country implemented all quality strategies at all hospitals. There were no differences between participating hospitals in western and eastern European countries regarding the application of quality improvement strategies. CONCLUSIONS: Implementation varied per country and per quality improvement strategy, leaving considerable scope for progress in quality improvements. The results may contribute to benchmarking activities in European countries, and point to further areas of research to explore the relationship between the application of quality improvement strategies and actual hospital performance.

Differentiating between hospitals according to the "maturity" of quality improvement systems: a new classification scheme in a sample of European hospitals.

AIM: This study, part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project focusing on cross-border patients in Europe, investigated quality policies and improvement in healthcare systems across the European Union (EU). The aim was to develop a classification scheme for the level of quality improvement (maturity) in EU hospitals, in order to evaluate hospitals according to the maturity of their quality improvement activities. METHODS: A web-based questionnaire survey designed to measure quality improvement in EU hospitals was used as the basis for the classification scheme. Items included for the development of an evaluation tool--the maturity index--were considered important contributors to quality improvement. The four-stage quality cycle (plan, do, check and act) was used to determine the level of maturity of the various items. Psychometric properties of the classification scheme were assessed, and validation analyses were performed. RESULTS: A total of 389 hospitals participated in a questionnaire survey; response rates varied by country. For a final sample of 349 hospitals, it was possible to construct a quality improvement maturity index which consisted of seven domains and 113 items. The results of independent analyses sustained the validity of the index, which was useful in differentiating between hospitals in the research sample according to the maturity of their quality improvement system (defined as the total of all quality improvement activities). DISCUSSION: Further research is recommended to develop an instrument which for use in the future as a practical tool to evaluate the maturity of hospital quality improvement systems.

Do European hospitals have quality and safety governance systems and structures in place?

Internal systems for quality and safety were assessed in 89 hospitals in six European states, by external teams using standardised criteria and procedures, as part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project. The assessments were made primarily to identify the current use of quality management systems in the sample hospitals, and also to demonstrate a potential tool for comparable assessment of hospitals in general. The large majority of the hospitals had a formal, documented infrastructure to manage quality and safety, but a significant minority had no designated mission, programme or coordination. In two-thirds of hospitals, the governing body was active in defining policy and programmes for improvement, and received reports on quality, safety and patient satisfaction at least once a year. The brief on-site assessments identified systematic variations, within and between countries, in structures and processes of governance and to document the uptake of best practice. Unacceptable variations in practice could be reduced, to the benefit of consumers and providers, by developing and publishing basic organisational standards relevant to all European states. The simple assessment criteria designed for this project could be developed into a practical tool for self-assessment, peer review or benchmarking of hospitals across national borders. This assessment, combined with explicit, relevant and achievable standards, could provide a vehicle to promote the voluntary uptake of best practice and consistency in quality and safety among hospitals in Europe.

Implementation of patient safety strategies in European hospitals.

CONTEXT: This study is part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on cross-border care, investigating quality improvement strategies in healthcare systems across the European Union (EU). AIM: To explore to what extent a sample of acute care European hospitals have implemented patient safety strategies and mechanisms and whether the implementation is related to the type of hospital. METHODS: Data were collected on patient safety structures and mechanisms in 389 acute care hospitals in eight EU countries using a web-based questionnaire. Subsequently, an on-site audit was carried out by independent surveyors in 89 of these hospitals to assess patient safety outputs. This paper presents univariate and bivariate statistics on the implementation and explores the associations between implementation of patient safety strategies and hospital type using the chi(2) test and Fisher exact test. RESULTS: Structures and plans for safety (including responsibilities regarding patient safety management) are well developed in most of the hospitals that participated in this study. The study found greater variation regarding the implementation of mechanisms or activities to promote patient safety, such as electronic drug prescription systems, guidelines for prevention of wrong patient, wrong site and wrong surgical procedure, and adverse events reporting systems. In the sample of hospitals that underwent audit, a considerable proportion do not comply with basic patient safety strategies--for example, using bracelets for adult patient identification and correct labelling of medication.

Impact of quality strategies on hospital outputs.

CONTEXT: This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on patients crossing borders, a study to investigate quality improvement strategies in healthcare systems across the European Union (EU). AIM: To explore the association between the implementation of quality improvement strategies in hospitals and hospitals' success in meeting defined quality requirements that are considered intermediate outputs of the care process. METHODS: Data regarding the implementation of seven quality improvement strategies (accreditation, organisational quality management programmes, audit and internal assessment of clinical standards, patient safety systems, clinical practice guidelines, performance indicators and systems for obtaining patients' views) and four dimensions of outputs (clinical, safety, patient-centredness and cross-border patient-centredness) were collected from 389 acute care hospitals in eight EU countries using a web-based questionnaire. In a second phase, 89 of these hospitals participated in an on-site audit by independent surveyors. Pearson correlation and linear regression models were used to explore associations and relations between quality improvement strategies and achievement of outputs. RESULTS: Positive associations were found between six internal quality improvement strategies and hospital outputs. The quality improvement strategies could be reasonably subsumed under one latent index which explained about half of their variation. The analysis of outputs concluded that the outputs can also be considered part of a single construct. The findings indicate that the implementation of internal as well as external quality improvement strategies in hospitals has beneficial effects on the hospital outputs studied here. CONCLUSION: The implementation of internal quality improvement strategies as well as external assessment systems should be promoted.