Diagnostic Performance of Airway Ultrasound for the Assessment of Difficult Laryngoscopy: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study aimed to review and appraise the evidence regarding airway ultrasound assessment in predicting difficult laryngoscopy in adult patients. DESIGN: A systematic review of the literature was conducted according to the Cochrane collaboration guidelines and the recommendations for the systematic review and meta-analysis of diagnostic studies. Observational studies that evaluated the diagnostic performance of airway ultrasound for the prediction of difficult laryngoscopy were included for consideration. SETTING: Literature searches were performed in 4 databases (PubMed [Medline], Embase, Clinical Trials, and Google Scholar) to identify all observational studies using any ultrasound technique to assess difficult laryngoscopy. The search terms included "sonography," "ultrasound," "airway," "difficult airway," "difficult laryngoscopy," "Cormack," "risk factors," "ultrasound at the point of care," "difficult ventilation," "difficult intubation" and others, combined with sensitive filters. The search was done for studies performed in the last 20 years in English or Spanish. PARTICIPANTS: Adult patients older than 18 years old under general anesthesia for an elective procedure. Evident anatomic airway abnormalities, obstetric populations, those using an alternative imaging method besides ultrasound, and animal studies were excluded. INTERVENTIONS: Preoperative bedside ultrasound measuring distances and ratios from the skin to different reference points, such as the ratio of the hyomental distance in a neutral position (HMDN) and hyomental distance in extension (HMDR), HMDN, and the skin-to-epiglottis distance (SED), the preepiglottic area, and tongue thickness, among others. MEASUREMENTS AND MAIN RESULTS: A total of 24 studies evaluated the prediction of a difficult laryngoscopy using airway ultrasound. The diagnostic performance and the number of ultrasound parameters reported in the studies were variable. Meta-analysis was performed for 3 measurements consistently included in most studies. The SED and the HMDR ratio presented a sensitivity of 75% and 61%, respectively, and a specificity of 86% and 88%, respectively. The ratio of the preepiglottic distance to the epiglottic distance at the midpoint of the vocal cords (pre-E/E-VC) presented the best performance for predicting a difficult laryngoscopy (sensitivity: 82%, specificity: 83%, diagnostic odds ratio: 22.2). CONCLUSION: With the currently available evidence, the 3 commonly used point-of-care ultrasound measures used to identify difficult laryngoscopy, (SED, HMDR, and pre-E/E-VC), showed better sensitivity and similar specificity to clinical measures. Future studies and more data may change the authors' confidence in these conclusions, given the wide variability of measurements noted in studies.

Impact of My Dose Coach App Frequency of Use on Clinical Outcomes in Type 2 Diabetes.

INTRODUCTION: My Dose Coach (MDC) is a US Food and Drug Administration-approved digital smartphone application designed to help users with type 2 diabetes (T2D) titrate their basal insulin (BI) according to a clinician-prescribed individualized titration plan. The aim of this analysis was to assess the impact of the frequency of MDC use on clinical outcomes. METHODS: This retrospective observational analysis included people with T2D who were registered for MDC (August 1st, 2018-April 30th, 2020) and received BI. Users with an activated care plan and ≥2 fasting blood glucose (FBG) observations spanning ≥2 weeks were defined as active. Outcomes included percentage achieving their individual FBG target, time to FBG target, change in FBG, change in insulin dose and hypoglycemia. Users were stratified into high (>3 days per week), moderate (>1- ≤3 days per week), and low (≤1 day per week) MDC usage groups. RESULTS: The analysis included 2517 active MDC users. Approximately 49% of users had high MDC usage. Overall, 44% of users across all usage frequencies achieved their individual FBG target. High MDC use was associated with significantly better FBG target achievement and less time to FBG target versus moderate- and low-usage groups (p≤0.01 for all). Insulin dose change was significantly greater in the high- versus moderate-usage group (p=0.01). There was no significant difference in hypoglycemia incidence among MDC usage groups (12%-16% of users in any usage group). CONCLUSIONS: More frequent MDC usage was associated with better FBG outcomes without increased hypoglycemia risk.

Measuring patient safety climate in operating rooms: Validation of the Spanish version of the hospital survey on patient safety.

OBJECTIVE: The measurement of patient safety climate within hospitals, and specifically in operating rooms is a basic tool for the development of the patient's safety policy. There are no validated Spanish versions of instruments to measure safety climate. The objective of this research was to validate the Spanish version of the Hospital Survey on Patient Safety (HSOPS®), with the addition of a module for surgical units, to evaluate the patient safety climate in operating rooms. METHODS: Survey validation study. The Hospital Survey on Patient Safety (HSOPS®) was applied to health workers from 6 acute general hospitals, from Medellín (Colombia), with surgical procedures greater than 300 per month, 18 items were added considered specific for Operating Rooms. For construct validation, an exploratory factor analysis (EFA) was used, utilizing principal components as the extraction method. Reliability was evaluated with Cronbach's α. RESULTS: A 10 dimensions model was obtained with EFA, most of the dimensions of the original questionnaire were conserved, although the factorial structure was not reproduced. Two new dimensions emerged from the added items. The Cronbach's α ranged between 0.66 and 0.87. Conclusions: We found the HSOPS questionnaire is valid and reliable for measuring patient safety climate in Spanish speaking Latin American countries. Two additional dimensions are proposed for Operating Rooms.

A review of flash glucose monitoring in type 2 diabetes.

BACKGROUND: Continuous glucose monitoring systems are increasingly being adopted as an alternative to self-monitoring of blood glucose (SMBG) by persons with diabetes mellitus receiving insulin therapy. MAIN BODY: The FreeStyle Libre flash glucose monitoring system (Abbott Diabetes Care, Witney, United Kingdom) consists of a factory-calibrated sensor worn on the back of the arm which measures glucose levels in the interstitial fluid every minute and stores the reading automatically every 15 min. Swiping the reader device over the sensor retrieves stored data and displays current interstitial glucose levels, a glucose trend arrow, and a graph of glucose readings over the preceding 8 h. In patients with type 2 diabetes (T2D) receiving insulin therapy, pivotal efficacy data were provided by the 6-month REPLACE randomized controlled trial (RCT) and 6-month extension study. Compared to SMBG, the flash system significantly reduced the time spent in hypoglycemia and frequency of hypoglycemic events, although no significant change was observed in glycosylated hemoglobin (HbA1c) levels. Subsequent RCTs and real-world chart review studies have since shown that flash glucose monitoring significantly reduces HbA1c from baseline. Real-world studies in both type 1 diabetes or T2D populations also showed that flash glucose monitoring improved glycemic control. Higher (versus lower) scanning frequency was associated with significantly greater reductions in HbA1c and significant improvements in other measures such as time spent in hypoglycemia, time spent in hyperglycemia, and time in range. Additional benefits associated with flash glucose monitoring versus SMBG include reductions in acute diabetes events, all-cause hospitalizations and hospitalized ketoacidosis episodes; improved well-being and decreased disease burden; and greater treatment satisfaction. CONCLUSION: T2D patients who use flash glucose monitoring might expect to achieve significant improvement in HbA1c and glycemic parameters and several associated benefits.

The effectiveness of a comprehensive diabetes program for glycemic control and adherence, and the selection of candidates for sensor-augmented insulin pump therapy.

OBJECTIVE: This study aimed to estimate the effectiveness of a comprehensive diabetes program (CDP) in terms of glycemic control, adherence, and the selection of candidates for sensor-augmented insulin pump therapy (SAP). METHODS: We compared diabetes control before and 6 months after CDP. The program was based on disease management using a logical model dealing with the following: case management, education and coaching, nutritional assessment, and mental health. RESULTS: The CDP improved glycemic control, HbA1c decreased by 0.56% (p-value=0.004; 95% CI: 0.14-0.98) and 19.1% of the patients reached the HbA1c goal without hypoglycemia. The CDP reduced by 52.4% the indication for SAP due to better glycemic control (36.4%) or non-adherence issues (63.6%); the remaining 47.6% persisted with poor glycemic control despite good adherence and were scaled to SAP. Among the 30 suitable candidates for SAP therapy, 60% did not reach the HbA1c goal and 40% had either hypoglycemic episodes (severe or persistent) or dawn phenomenon. The overall non-adherence rate was 33.3%. CONCLUSIONS: CDP optimized the selection of suitable candidates for SAP by improving glycemic control and identifying adherence issues early. These results provide evidence of the impact of the implementation of patient selection and educational protocols in the real-life setting of a highly experienced clinic.

The effectiveness of a comprehensive diabetes program for glycemic control and adherence, and the selection of candidates for sensor-augmented insulin pump therapy.

OBJECTIVE: This study aimed to estimate the effectiveness of a comprehensive diabetes program (CDP) in terms of glycemic control, adherence, and the selection of candidates for sensor-augmented insulin pump therapy (SAP). METHODS: We compared diabetes control before and 6 months after CDP. The program was based on disease management using a logical model dealing with the following: case management, education and coaching, nutritional assessment, and mental health. RESULTS: The CDP improved glycemic control, HbA1c decreased by 0.56% (p-value=0.004; 95% CI: 0.14-0.98) and 19.1% of the patients reached the HbA1c goal without hypoglycemia. The CDP reduced by 52.4% the indication for SAP due to better glycemic control (36.4%) or non-adherence issues (63.6%); the remaining 47.6% persisted with poor glycemic control despite good adherence and were scaled to SAP. Among the 30 suitable candidates for SAP therapy, 60% did not reach the HbA1c goal and 40% had either hypoglycemic episodes (severe or persistent) or dawn phenomenon. The overall non-adherence rate was 33.3%. CONCLUSIONS: CDP optimized the selection of suitable candidates for SAP by improving glycemic control and identifying adherence issues early. These results provide evidence of the impact of the implementation of patient selection and educational protocols in the real-life setting of a highly experienced clinic.

Real-world effectiveness and safety of sensor-augmented insulin pump therapy in adults with type 1 diabetes: Long-term follow-up.

OBJECTIVE: To evaluate the effectiveness and safety of sensor-augmented insulin pump therapy (SAP) in addition to a comprehensive diabetes program on glycated hemoglobin (HbA1c), severe hypoglycemia, ketoacidosis, and the hospital admission rate in patients with type 1 diabetes under real-world settings during a 2-year follow-up. METHODS: This was a retrospective real-life study comparing diabetes control before and after SAP therapy initiation. Patients ≥18 years old with type 1 diabetes were included. They were followed for 2 years with clinical assessments at months 3, 6, 12, 18, and 24. Effectiveness was estimated by difference in medians of HbA1c from baseline and at each follow-up visit. Safety was assessed by comparing the annual rates of severe hypoglycemia, hyperglycemic crisis, and hospital admission related to diabetes. RESULTS: 162 patients were included, median age 32 years, women 73%). The main indication for SAP was poor metabolic control (51.2%). At 2 years HbA1c decreased from 8.4% to 7.5% (-0.9%, 95% CI: 0.5-1.2; p<0.0001), HbA1c ≤7% improved from 14.2% to 25.3% (11.1%, 95% CI: 19.7-2.5; p=0.006), and severe hypoglycemia decreased from 22.2% to 14.1% (-8.1%, 95% CI: -16.5 to 0.3; p=0.03). CONCLUSIONS: SAP therapy improved glycemic control after the third month of use and for up to 2 years of follow-up, with lower rates of hospital admission and severe hypoglycemia. More studies are needed to assess the add-on impact of education programs and technologies for diabetes care.

Real-world effectiveness and safety of sensor-augmented insulin pump therapy in adults with type 1 diabetes: Long-term follow-up.

OBJECTIVE: To evaluate the effectiveness and safety of sensor-augmented insulin pump therapy (SAP) in addition to a comprehensive diabetes program on glycated hemoglobin (HbA1c), severe hypoglycemia, ketoacidosis, and the hospital admission rate in patients with type 1 diabetes under real-world settings during a 2-year follow-up. METHODS: This was a retrospective real-life study comparing diabetes control before and after SAP therapy initiation. Patients ≥18 years old with type 1 diabetes were included. They were followed for 2 years with clinical assessments at months 3, 6, 12, 18, and 24. Effectiveness was estimated by difference in medians of HbA1c from baseline and at each follow-up visit. Safety was assessed by comparing the annual rates of severe hypoglycemia, hyperglycemic crisis, and hospital admission related to diabetes. RESULTS: 162 patients were included, median age 32 years, women 73%). The main indication for SAP was poor metabolic control (51.2%). At 2 years HbA1c decreased from 8.4% to 7.5% (-0.9%, 95% CI: 0.5-1.2; p<0.0001), HbA1c ≤7% improved from 14.2% to 25.3% (11.1%, 95% CI: 19.7-2.5; p=0.006), and severe hypoglycemia decreased from 22.2% to 14.1% (-8.1%, 95% CI: -16.5 to 0.3; p=0.03). CONCLUSIONS: SAP therapy improved glycemic control after the third month of use and for up to 2 years of follow-up, with lower rates of hospital admission and severe hypoglycemia. More studies are needed to assess the add-on impact of education programs and technologies for diabetes care.

Clima de seguridad del paciente en cuatro servicios quirúrgicos de Santander / Patient Safety Climate in four Santander surgical units

Resumen Introducción: Conocer la percepción del clima de seguridad al interior de los servicios quirúrgicos es una tarea importante para establecer acciones que reduzcan el riesgo de eventos adversos durante la atención del paciente. Objetivo: Caracterizar el clima de seguridad en los servicios quirúrgicos de cuatro instituciones de salud de Santander. Materiales y métodos: Estudio observacional de corte transversal. Se aplicó el instrumento Hospital Survey on Patient Safety. Los resultados se reportaron como los promedios de repuestas positivas y negativas. Se analizaron las características asociadas a las dimensiones con mayores puntajes de percepción negativa. Resultados: Participaron 164 trabajadores. Las dimensiones con mayor percepción positiva fueron prácticas seguras (84 %), dotación de personal (83,2 %) y aprendizaje organizacional (78,4 %). Las dimensiones con percepción desfavorable fueron respuesta no punitiva al error (40,2 %), carga de trabajo (51,7 %), comunicación (54,3 %) y transiciones y transferencias entre servicios (58,1 %). Se encontró asociación entre una baja percepción en las transiciones y transferencias entre servicios con la contratación por prestación de servicios y con el cargo Médico Especialista y Anestesiólogo. Los bajos puntajes en comunicación se asociaron a la contratación gremial. No se encontraron factores asociados para las dimensiones respuesta no punitiva al error y carga de trabajo. Conclusiones: La percepción sobre clima seguridad en general es considerada positiva, aunque existen oportunidades de mejora. Los factores como tipo de contratación y cargo se asociaron a una percepción negativa de clima de seguridad. Los trabajadores se sienten juzgados al reportar eventos adversos.

Abstract Introduction: Knowing the perception of the safety climate within surgical services has become an important task to establish actions that reduce the risk of suffering adverse events during patient care. Objective: To characterize the safety climate in the surgical services of four health institutions in Santander. Materials and methods: Observational cross-sectional study. The Hospital Survey on Patient Safety instrument was applied. The results were reported as the means of positive and negative responses. The characteristics associated with the dimensions with the highest negative perception scores were analyzed. Results: 164 workers participated. The dimensions with the highest positive perception were safe practices (84 %), staffing (83.2 %) and organizational learning (78.4 %); Dimensions with unfavorable perception were non-punitive response to error (40.2 %), workload (51.7 %), communication (54.3 %) and transitions and transfers between services (58.1 %). Association between a low perception in transitions and transfers between services with contracting for the provision of services and with the position of Specialist (Physician and Anesthesiologist) was found. Low scores in communication were associated with union hiring. No associated factors were found for the non-punitive response to error and workload dimensions. Conclusions In general, the perception of safety climate is considered positive, although there are opportunities for improvement. Factors such as type of hiring and position were more associated with negative perception. Workers feel judged when reporting adverse events.

Clinical Outcomes After 1 Year of Augmented Insulin Pump Therapy in Patients with Diabetes in a Specialized Diabetes Center in Medellín, Colombia.

BACKGROUND: Type 1 diabetes can be difficult to control. Augmented pump therapy (CSII-rtCGM) has become an important tool for controlling blood glucose and decreasing hypoglycemia. METHODS: Describe the results 1 year after starting CSII-rtCGM in patients with diabetes in Medellín, Colombia. This is an observational, retrospective study. Patients with type 1 and type 2 diabetes started on CSII-rtCGM between January 2008 and June 2015 were included. Qualitative variables were analyzed as absolute or relative frequencies. Quantitative variables were obtained through central tendency and dispersion according to the normal distribution of the analyzed variable using Kolmogorov-Smirnov. SPSS 19 from IBM was used. RESULTS: Two hundred forty-seven patients were identified, of those 183 were included. The starting HbA1C was 8.7% ± 1.7% and 7.4% ± 0.8% (P < 0.05) 1 year later. 16.5% of patients had been admitted to the hospital before starting CSII-rtCGM, after 1 year the admission rate was 6.0% (P < 0.05). The incidence of severe hypoglycemia at the beginning was 32%, 1 year later it was 7.1%. CONCLUSION: CSII-rtCGM therapy improves glucose control and decreases severe hypoglycemic events and hospital admission rate.

Evaluación de la prueba de avidez para el seguimiento de niños tratados por toxoplasmosis congénita durante el primer año de vida / Evaluation of the avidity test for the follow up on children treated for congenital toxoplasmosis during the first year of life

RESUMEN Objetivos: determinar la utilidad de la prueba de avidez en el seguimiento de los pacientes diagnosticados con toxoplasmosis congénita a través de la evaluación de su comportamiento en el tiempo. Metodología: estudio retrospectivo a partir de los datos en historias clínicas de niños que tuvieron confirmación diagnóstica y tratamiento para toxoplasmosis congénita, realizado en consulta de toxoplasmosis, tercer nivel de referencia en el centro de salud de la Universidad del Quindío. Se estudiaron 21 niños que fueron seleccionados de una cohorte inicial de 168 pacientes, reclutados en los programas de tamizaje prenatal y los programas de prevención o niños que acudieron para el diagnóstico neonatal. Resultados: no se encontró relación estadísticamente significativa entre el porcentaje de avidez baja en el primer mes y haber recibido tratamiento prenatal (p = 0,47). Tampoco entre la primera y los niveles de IgG o los meses de vida, a pesar de haber recibido tratamiento posnatal. Sin embargo, al estudiar específicamente el grupo de niños de 5 meses de edad, se encontró una correlación significativa con los niveles de IgG anti-Toxoplasma (p = 0,01). Conclusión: en esta cohorte de niños colombianos con toxoplasmosis congénita se encontraron los mismos resultados reportados en series previas con un mayor número de casos en Italia. La avidez no mostró ser útil para el seguimiento de los niños con toxoplasmosis congénita.

SUMMARY Objectives: To determine the use of avidity testing in the follow up of patients diagnosed with congenital toxoplasmosis, through the observation of its behavior in time. Methods: Retrospective study from clinical records of children with confirmed diagnosis and treatment for congenital toxoplasmosis, which took place on atoxoplasmosis consultation in the third reference level University of Quindío clinic. A total of 21 children were selected among an initial cohort of 168 patients, recruited during prenatal screening, neonatal screening or children that attended for neonatal diagnosis. Results: There was no statistical significance found between low avidity during the first month and having received prenatal treatment (p=0,47). There was no statistical relationship either between the percentage of avidity and the levels of IgG or the months of age, despite having received postnatal treatment. Nevertheless, when studying specifically the group of children > 5 months of age a significant correlation was found with levels of IgG (p=0,01). Conclusion: In this cohort of Colombian children with congenital toxoplasmosis, the same results were found comparing with those reported in series with greater number of cases. Avidity testing did not prove to be useful for the follow up of children with congenital toxoplasmosis.

Epidemiological characterization of diabetic patients on therapy with continuous subcutaneous insulin infusion and continuous glucose monitoring in real time.

OBJECTIVE: To describe baseline characteristics of diabetic patients who were started on insulin pump and real time continuous glucose monitor (CSII-rtCGM) in a specialized center in Medellin, Colombia. MATERIALS AND METHODS: All patients with diabetes with complete data who were started on CSII-rtCGM between February 2010 and May 2014 were included. This is a descriptive analysis of the sociodemographic and clinical characteristics. RESULTS: 141 of 174 patients attending the clinic were included. 90,1% had type 1diabetes (T1D). The average age of T1D patients at the beginning of therapy was 31,4 years (SD 14,1). 75.8% of patients had normal weight (BMI<25), 21.0% were overweight (BMI 25-30) and 2,3% were obese (BMI>30). The median duration of T1D was 13 years (P25-P75=10.7-22.0). 14,2% of the patients were admitted at least once in the year preceding the start of CSII-rtCGM because of diabetes related complications. Mean A1c was 8.6%±1.46%. The main reasons for starting CSII-rtCGM were: poor glycemic control (50.2%); frequent hypoglycemia, nocturnal hypoglycemia, hypoglycemia related to exercise, asymptomatic hypoglycemia (30.2%); severe hypoglycemia (16.44%) and dawn phenomena (3.1%). CONCLUSION: Baseline characteristics of patients included in this study who were started on CSII-rtCGM are similar to those reported in the literature. The Clinic starts CSII-rtCGM mainly in T1D patients with poor glycemic control, frequent or severe hypoglycemia despite being on basal/bolus therapy.

Gastrectomía laparoscópica casi total con preservación de la rama ascendente de la arteria gástrica izquierda y un 5 % de remanente gástrico. ¿Existe relación con las complicaciones de la anastomosis? / Almost total laparoscopic gastrectomy with preservation of the ascending branch of the left gastric artery and 5 % gastric remnant. Is there a relationship with the complications of the anastomosis

Introducción. Al realizar una gastrectomía distal, el remanente gástrico es irrigado por los vasos gástricos cortos. En este estudio presentamos una serie de casos de gastrectomía distal laparoscópica, con la variante de preservar la rama superior de la arteria gástrica izquierda, con un remanente gástrico pequeño. Métodos. Estudio observacional con intensión analítica, seguimiento de una cohorte retrospectiva de pacientes con cáncer gástrico sometidos a gastrectomía distal radical laparoscópica entre enero 2017 y junio 2019. Se incluyeron todos los pacientes con cáncer gástrico a quienes se les realizó gastrectomía distal radical por laparoscopia. Se estudiaron variables clínicas de los pacientes, variables intraoperatorias, información relacionada con el informe de patología y las complicaciones de la anastomosis gastro-yeyunal. Resultados. Se revisó un total de 61 historias clínicas de pacientes sometidos a gastrectomía distal por laparoscopia, entre quienes se encontró la preservación de la rama ascendente de la arteria gástrica izquierda en el 73,8 % de los pacientes (n=45). El promedio de ganglios resecados fue de 24. Se presentaron un total de 10 complicaciones, ocho relacionadas con la anastomosis (tres estenosis, cuatro filtraciones y un paciente con hemorragia del tracto digestivo superior), y dos con colecciones intrabdominales. En el análisis estadístico no se encontró relación entre la preservación de la rama ascendente de la arteria gástrica izquierda con la presencia de complicaciones. Discusión. La variación que presentamos de la técnica de la gastrectomía distal por laparoscopia cumple con los requisitos oncológicos en los pacientes con cáncer gástrico y no se relaciona con complicaciones de la anastomosis gastro-yeyunal

Introduction. When performing a distal gastrectomy, the gastric remnant is supplied by the short gastric vessels. In this study we present a series of cases of laparoscopic distal gastrectomy, with the variant of preserving the superior branch of the left gastric artery, with a small gastric remnant.Methods. Observational study, follow-up of a retrospective cohort of patients with gastric cancer who underwent laparoscopic radical distal gastrectomy between January 2017 and June 2019. All patients with gastric cancer who underwent laparoscopic radical distal gastrectomy were included. Clinical variables of the patients, intraopera-tive variables, information related to the pathology report and complications of the gastro-jejunal anastomosis were studied.Results. A total of 61 medical records of patients undergoing laparoscopic distal gastrectomy were reviewed; pres-ervation of the ascending branch of the left gastric artery was found in 73.8% of the patients (n = 45). The average number of lymph nodes resected was 24. There were a total of 10 complications, eight related to the anastomosis (three strictures, four leaks and one patient with bleeding from the upper digestive tract), and two patients who presented intra-abdominal collections. No statistical relationship was found between the preservation of the ascending branch of the left gastric artery and the presence of complications.Discusion. The variation that we present of the laparoscopic distal gastrectomy technique meets the oncological requirements in patients with gastric cancer and is not related to complications of the gastrojejunal anastomosis.

Patient safety climate in operating rooms at Colombian hospitals: differences by profession and type of contract / Clima de seguridad del paciente en unidades quirúrgicas de hospitales colombianos: diferencias por profesión y tipo de contratación

Abstract Introduction: The safety climate (SC) measurement in the hospitals, is essential for the development of a patient safety policy (PSP). Information about SC in the operating rooms is scarce. Objective: To measure the dimensions of SC in Colombian Operating Rooms according to characteristics of surgical staff. Methods: Cross-sectional study. The Hospital Survey on Patient Safety and an additional module for operating rooms were administered to healthcare workers in 6 high-complexity hospitals in the Metropolitan Area of Medellín (Colombia). The positive responses percentage for each dimension was measured. Differences by profession and type of contract were analyzed. Results: A total of442 participants were included. The workers in the operating rooms perceive a weak SC in terms of non-punitive response to error and workload (49.4% and 59.3% positive responses, respectively). Differences were found between physicians and nurses with lower scores in nursing for dimensions related to patient care. Anesthesiologists present low scores in events reporting. There are also differences by the type of work contract. Conclusion: Despite the PSP, the perception of a punitive culture to error, with a high workload. Recognizing differences between the groups within the surgical units helps to focus interventions strengthening the patient safety.

Resumen Introducción: La medición del clima de seguridad (CS) en las instituciones de salud es parte fundamental del desarrollo de una política de seguridad del paciente (PSP). Existe poca información acerca de la medición de clima de seguridad en las unidades quirúrgicas. Objetivo: Medir las dimensiones del CS en las unidades quirúrgicas de seis instituciones de salud colombianas según las características del personal. Métodos: Estudio de corte transversal. El cuestionario sobre seguridad del paciente en los hospitales (HSOPS) más la adición de un módulo para unidades quirúrgicas se aplicó al personal de seis hospitales de III nivel de Medellín (Colombia). Se midió el porcentaje de respuestas positivas para cada dimensión del CS. Se analizaron las diferencias por profesión y tipo de contratación. Resultados: Se incluyeron 442 participantes. El personal de las unidades quirúrgicas percibe un CS débil en respuesta no punitiva al error y carga de trabajo (49,4 % y 59,3 % de respuestas positivas respectivamente). Se encontraron diferencias entre personal médico y de enfermería con puntajes más bajos de percepción de CS en enfermería para aquellas dimensiones relacionadas con cuidado del paciente. Los anestesiólogos presentan puntajes bajos en el reporte de eventos. Existen además diferencias según el tipo de contrato de trabajo. Conclusiones: A pesar de la implementación de políticas de seguridad del paciente, persiste la percepción de una cultura punitiva frente al error, con una carga de trabajo elevado. El reconocimiento de las diferencias entre los grupos en las unidades quirúrgicas permitirá focalizar intervenciones que fortalezcan la seguridad del paciente.

A configuração das práticas de cuidado da saúde mental juvenil em Medellín e Porto Alegre: uma narrativa de si / The configuration of youth mental health care practices in Medellín and Porto Alegre: a narrative of self / La configuración de las prácticas de cuidado de la salud mental juvenil en Medellín y Porto Alegre: una narrativa de sí / La configuration des pratiques de santé mentale des jeunes à Medellín et à Porto Alegre: un récit de soi

O artigo reflete sobre as maneiras de produção da saúde mental juvenil, desde uma visão coletiva, sistêmica e interdisciplinar, nas cidades de Medellín (Colômbia) e Porto Alegre (Brasil). O objetivo foi compreender como se configuram as práticas de cuidado da saúde mental de jovens nos cenários das duas cidades. A narrativa de si foi a perspectiva metodológica utilizada e o processo analítico compreendeu o arco hermenêutico proposto por Paul Ricoeur. Os resultados mostram que as práticas de cuidado da saúde mental juvenil se configuram como processos em rede, na dimensão estrutural e na dimensão micropolítica. A disponibilidade, a cotidianidade e a continuidade são atributos dessa rede de relações. Discute-se o conceito de saúde mental como tensão de forças individuais e coletivas, assim como a potência da resistência e das noções de cuidado de si e dos outros.

This paper discusses the ways in which mental health takes place, from a collective, systemic and interdisciplinary point of view, in the cities of Medellin (Colombia) and Porto Alegre (Brazil). The goal of the study was to comprehend how youth mental health care practices are configured in both cities. The narrative of the self was used as methodological perspective, and the analysis consisted of Paul Ricoeur's hermeneutic arc. The results show that youth mental health care practices are configured as network processes, in structural and micropolitical dimensions. Availability, continuity and daily happenings are attributes of the network. Mental health as a concept is discussed as a tension of individual and collective forces. Also, the power of resistance and the notions of care of the self and care of the others are examined.

El artículo reflexiona sobre las maneras en que se produce la salud mental juvenil, desde una visión colectiva, sistémica e interdisciplinar, en las ciudades de Medellín (Colombia) y Porto Alegre (Brasil). El objetivo fue comprender como se configuran las prácticas de cuidado de la salud mental juvenil en los escenarios de las dos ciudades. La narrativa de si fue la perspectiva metodológica utilizada y el proceso de análisis comprendió el arco hermenéutico propuesto por Paul Ricoeur. Los resultados muestran que las prácticas de cuidado de la salud mental juvenil se configuran como procesos en red, en la dimensión estructural y en la dimensión micropolítica. La disponibilidad, la cotidianidad y la continuidad son atributos de esa red de relaciones. Se discute el concepto de salud mental como tensión de fuerzas individuales y colectivas, así como la potencia de la resistencia y de las nociones de cuidado de si y de los otros.

L'article se penche sur les moyens de produire la santé mentale des jeunes, dans une perspective collective, systémique et interdisciplinaire, dans les villes de Medellín (Colombie) et de Porto Alegre (Brésil). L'objectif était de comprendre comment sont configurées les pratiques de soins de santé mentale des jeunes dans les scénarios des deux villes. Le récit de luimême était la perspective méthodologique utilisée et le processus analytique comprenait l'arc herméneutique proposé par Paul Ricoeur. Les résultats montrent que les pratiques des soins de santé mentale des jeunes sont configurées comme des processus de réseau, dans la dimension structurelle et dans la dimension micropolitique. La disponibilité, le quotidien et la continuité sont les attributs de ce réseau de relations. Le concept de santé mentale est discuté comme la tension des forces individuelles et collectives, ainsi que le pouvoir de résistance et les notions de prise en charge de soi et des autres.

Síndrome de Cushing exógeno e insuficiencia adrenal relacionada con consumo de producto natural / Exogenous Cushing's syndrome and adrenal insufficiency related to consumption of alternative medicinal product

Resumen La insuficiencia adrenal es una endocrinopatía cuya principal causa se debe a la deficiencia en la producción de hormona adrenocorticotrópica, generalmente explicada por factores iatrogénicos y en menor número de casos al defecto primario de la glándula adrenal (enfermedad de Adisson). Su diagnóstico y la búsqueda de una etiología específica es muy importante, dado las implicaciones a largo plazo que conlleva por necesidad de suplencia hormonal, manejo en condiciones críticas, riesgo de muerte y compromiso de la actividad laboral. Presentamos el caso de una mujer quien consultó por ganancia excesiva de peso, signos de hipercortisolismo e hipertensión, se documentó una probable fuente exógena de esteroides, encontrando un cortisol sérico suprimido. Dos años antes estaba recibiendo artrivid PLUS, un producto natural para el manejo del dolor articular. Después de suspender ésta medicación presentó síntomas compatibles con insuficiencia adrenal, requiriendo el reinicio de prednisolona, con mejoría clínica y logrando su desmonte gradual posterior. (Acta Med Colomb 2017; 42: 243-246).

Abstract Adrenal insufficiency is an endocrinopathy whose main cause is due to the deficiency in the production of adrenocorticotropic hormone, usually explained by iatrogenic factors and in a smaller number of cases to the primary defect of the adrenal gland (Adisson's disease). Diagnosis and the search for a specific etiology is very important, given the long-term implications involved by the need of hormone replacement, management in critical conditions, risk of death and the compromise of work activity. The case of a woman who consulted for excessive weight gain, signs of hypercortisolism and hypertension, is presented. A probable exogenous source of steroids was documented, finding a suppressed serum cortisol. Two years before she was receiving artrivid PLUS, a natural product for joint pain management. After stopping this medication, she presented symptoms compatible with adrenal insufficiency, requiring the resumption of prednisolone, with clinical improvement and achieving its subsequent gradual removal. (Acta Med Colomb 2017; 42: 243-246).

La cultura de la seguridad del paciente: enfoques y metodologías para su medición / The patient safety culture: approaches and methodologies for measurement

Resumen Introducción: El concepto de cultura de la seguridad del paciente se desarrolla en las denominadas "organizaciones de alta confiabilidad", como estrategia para enfrentar la problemática de los eventos adversos. Objetivo: Revisar los enfoques que han predominado en cultura de la seguridad del paciente y describir algunas herramientas que se han utilizado para su medición. Metodología: Revisión narrativa enfocada en la conceptualización de cultura de la seguridad. Resultados: El término cultura de la seguridad es utilizado por la literatura con varios significados. La polisemia del término y en particular la confusión con la noción de "clima de seguridad", implica también confusiones en los métodos e interpretación de las mediciones. Se identifican dos enfoques conceptuales básicos en el estudio de la cultura de la seguridad: el antropológico y el funcionalista, siendo este último el predominante en el desarrollo de instrumentos utilizados para su medición; estos últimos, sin embargo, presentan constructos y propiedades métricas variables. Conclusión: El estudio de la seguridad del paciente, como categoría en desarrollo, debería utilizar los enfoques de medición disponibles con una mirada crítica, integrando técnicas de entrevista y estudios cualitativos, en especial de tipo etnográfico, que suministren información más integral y útil en la toma de decisiones encaminadas a mejorar la seguridad y confiabilidad de la atención médica.

Abstract: Introduction: The notion of Patient Safety Culture has been developed strongly linked to the concept of "High Reliability Organizations", as a strategy to face the problem of adverse events. Objective: To review the approaches that have prevailed in Patient Safety Culture and describe some tools that have been used for its measurement. Methodology: Narrative review focused on the conceptualization of safety culture. Results: Technical literature uses the term safety culture with several meanings. The multiple meanings of the term, and particularly the vagueness with the term "safety climate" also involve confusions in the methods and interpretations of measurements. Two main conceptual approaches to the study of the safety culture were identified: the anthropological and the functionalist approaches, the latter being predominant in the development of instruments used to measure Patient Safety Culture, however, their constructs and their metric properties are widely heterogeneous. Conclusion: The study of patient safety as developing category, one should use the available measurement approaches with a critical view, integrating information from other sources such as interviews and qualitative studies, including ethnographic approach, to provide more comprehensive and useful tools in the decision-making process aimed at improving the safety and reliability of medical care.

Caracterización del funcionamiento de la unidad de cuidados postanestésicos a partir de la percepción del personal de enfermería profesional / Portrayal of the performance of the post-anesthesia care unit, based on the perception of the professional nursing staffs

ABSTRACT Introduction: The post-anesthesia care unit has been identified as a vulnerable area for the occurrence of adverse events. Here, the nursing staff is responsible for managing and taking care of patients. Objective: To explore the perception of the professional nursing staff about the performance of the post-anesthesia care unit, and portray certain aspects of its operations. Materials and methods: This is a mixed sequential study including an observational, descriptive and quantitative cross section phase and a qualitative, descriptive, interpretative phase, using grounded theory. Results: Nurses perceive the PACU as "a place for care" with weak processes such as patient handover and monitoring, communications among care providers, lack of specific skills of the ancillary staff and lack of teamwork. Work overload, extended administrative tasks that take away focus from patient care, in addition to a lack of compliance with protocols, are all conducive to the occurrence of adverse events. Conclusions: Nurses perceive the unit as a place of complex processes and particular char acteristics that make the unit prone to adverse events. Institutional factors, work team and professional-related aspects become threats that undermine the safety environment that should always prevail in every PACU. Specific strategies are discussed to turn the recovery unit into a safe care service for the surgical patient.

RESUMEN Introducción: La unidad de cuidados post anestésicos se ha identificado como un sitio vulne rable para la presentación de eventos adversos; en este lugar es el personal de enfermería quien se encarga del manejo y cuidado de los pacientes. Objetivo: Explorar las percepciones que tiene el personal de enfermería profesional acerca del funcionamiento de la unidad de cuidados post anestésicos y caracterizar algunos aspec tos de su funcionamiento. Materiales y métodos: Estudio con enfoque mixto secuencial: una fase cuantitativa descrip tiva observacional de corte transversal y una cualitativa de tipo descriptivo interpretativo utilizando teoría fundamentada. Resultados: Los enfermeros perciben la unidad de cuidados post anestésicos como «un sitio para el cuidado¼ con debilidades en procesos como la entrega y monitoreo de pacientes, la comunicación del personal asistencial, falencia en habilidades específicas del personal auxiliar y ausencia de trabajo en equipo. La sobrecarga de trabajo, un aumento de labores administrativas que desplazan el cuidado del paciente, así como la falta de adherencia a pro tocolos, son percibidos como situaciones que facilitan la presentación de eventos adversos. Conclusiones: La unidad es percibida por los enfermeros como un lugar de procesos comple jos y características particulares que la hacen susceptible de eventos adversos. Factores a nivel de la institución, el grupo de trabajo y el profesional se convierten en amenazas que socavan el ambiente de seguridad que debería prevalecer en un servicio de recuperación post anestésica. Se proponen estrategias específicas que impulsen a la unidad de recuperación como un servicio de atención segura para el paciente quirúrgico.

Caracterización y análisis de eventos adversos en procesos cerrados de anestesiólogos apoderados por la Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E. ) en Colombia entre 1993-2012 / Characterization and analysis of adverse events in closed liability cases involving anaesthetists who received legal support from the Colombian Society of Anaesthesia and Resuscitation (S.C.A.R.E.), Colombia, 1993-2012

Introduction: Adverse events are the source of significant care-related morbidity and mortality in surgical patients. Objective: To characterize and analyze anaesthesia-related adverse events in closed ethical and legal cases, with the involvement of the Colombian Society of Anaesthesia and Resuscitation (Sociedad Colombiana de Anestesiología y Reanimación - S.C.A.R.E.) between 1993 and 2012. Materials and methods: Retrospective analysis of medical liability cases involving anaesthetists, managed with the support of the Special Fund for Mutual Legal Assistance (FEPASDE). Results: Overall, 278 proceedings involving anaesthesia-related adverse events were analyzed. The majority (67%) occurred in association with planned surgical procedures (general surgery, orthopaedic surgery, plastic surgery, and obstetrics and gynaecology) performed under general anaesthesia in ASA I patients taken to surgery in Level II complexity settings. A substantial percentage of adverse events (18%) occurred in the Post-Anaesthetic Care Unit (PACU). The most frequent adverse events were cardiovascular and respiratory (55.4% and 36.7% respectively). The most predominant outcomes were death (50.3%) and cerebral insult (22.3%). The analysis found flaws in the completion of the pre-anaesthetic assessment and informed consent forms, compliance with guidelines, standards or protocols, communication with the patient or the family after the event, and communication among the members of the healthcare team. Conclusions: In the cases reviewed, the majority of adverse events happened in low risk patients, in low complexity institutions. The PACU was a sensitive setting for the occurrence of adverse events. It is important to consider environmental factors when analysing adverse events.

Introducción: Los eventos adversos generan una porción considerable de la morbimortalidad asociada a la atención del paciente quirúrgico. Objetivo: Caracterizar y analizar los eventos adversos asociados a procesos éticos y jurídicos cerrados de anestesiólogos, adelantados por la Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.) entre 1993-2012. Materiales y Métodos: Estudio retrospectivo que analiza información procesos de responsabilidad médica de anestesiólogos, gestionados por el Fondo Especial Para Auxilio Solidario de Demandas (FEPASDE). Resultados: Se analizaron 278 procesos con evento adverso relacionado con la anestesia, la mayoría (67%), ocurrieron en procedimientos quirúrgicos programados (en intervenciones de cirugía general, ortopedia, cirugía plástica y gineco-obstetricia), realizados bajo anestesia general, en pacientes ASA I, atendidos en segundo nivel de complejidad. Un porcentaje relevante de eventos adversos (18%) ocurrieron en la Unidad de Cuidados Postanestésicos (UCPA). Los eventos adversos más frecuentes fueron cardiovasculares y respiratorios (55,4% y 36,7% respectivamente). Los desenlaces que predominaron fueron muerte (50,3%) y lesión cerebral (22,3%). Se encontraron fallas en el diligenciamiento de la valoración preanestésica y consentimiento informado, adherencia a guías, normas o protocolos, comunicación con el paciente o su familia posterior al evento y comunicación entre el equipo de salud. Conclusiones: En los procesos revisados, la mayoría de eventos adversos se presentaron en pacientes de bajo riesgo y en instituciones de bajo nivel de complejidad. La UCPA fue un sitio vulnerable para la presentación de eventos adversos. Es importante considerar factores relacionados con el entorno en el análisis de los eventos adversos.