Identificación y análisis de eventos adversos ocurridos durante la atención de embarazadas en un hospital de nivel IIIB / Adverse event identification and analysis on pregnant women treated in a level IIIB hospital

Los incidentes son errores y fallas involuntarias. Cuando provocan un daño al paciente a partir de la asistencia sanitaria, se llaman eventos adversos (EA). El objetivo general fue describir los EA en embarazadas internadas. Específicamente, se buscó determinar la incidencia, estimar el impacto en días de internación y gravedad, describir las causas relacionadas con el diagnóstico, los procedimientos y la administración de medicamentos, y analizar la proporción de EA en gestantes con morbilidad materna severa (MMS). MÉTODOS: Se utilizó un diseño observacional, descriptivo y prospectivo con embarazadas y puérperas internadas entre julio y diciembre de 2018. Mediante un formulario de tamizaje se identificaron lesiones/complicaciones; en casos positivos, se evaluaron historias clínicas con un formulario modular para identificar EA y demás variables. RESULTADOS: Se incluyó a 1914 mujeres; hubo 98 con uno o más criterios positivos; 42 tuvieron un EA (2,19%; IC95%: 1,58- 2,95). Aumentaron los días de internación en 18 casos, con 19 (45,2%) de EA moderados y 19 (45,2%) graves, 24 (57%) de errores de diagnóstico, 24 (57%) de procedimiento y 11 (26%) relacionados con medicamentos. El 75% de EA se relacionó con MMS. DISCUSIÓN: La incidencia de EA fue baja, pero con un alto porcentaje de eventos graves. La cantidad de días de internación adicionales fue baja. Los errores de diagnóstico y procedimiento ocurrieron en más del 50% de los eventos, con menos errores de medicamentos. En dos de cada tres pacientes con MMS hubo un EA.

El sufrimiento mental en el trabajo: burnout en médicos de un hospital de Alta Complejidad, Corrientes / Mental suffering at work: burnout in doctors hospital High Complexity, Corrientes

Introducción: El síndrome de Burnout (SBO) es una respuesta inadecuada a un estrés emocional crónico consecuencia de elevados niveles de tensión en el trabajo, frustración personal y actitudes inadecuadas de enfrentamiento a situaciones conflictivas. Objetivos: determinar la prevalencia de SBO en médicos de un hospital general de alta complejidad de la ciudad de Corrientes; identificar factores asociados y causales; establecer un indicador preventivo para evitar o retardar el desarrollo de SBO (l CBO). Materiales y Métodos: se realizó un estudio transversal, observacional, que incluyo a 141 médicos. Se utilizó el Cuestionario Breve de Burnout de Bernardo Moreno. La población fue dividida en cinco grupos según el servicio donde se desempeñan: grupo 1 (quirófano), grupo 2 (perinatología), grupo 3 (clínica), grupo 4 (urgencias) y grupo 5 (varios). Se construyo una curva ROC y se determinó un punto de corte para predecir SBO. Se realizó un análisis univariado y tres multivariados. Resultados: la prevalencia de SBO fue del 44% (n=62). La edad media fue 49.9±9.1 años. El punto de corte de total CBO ≥ 21, tuvo una sensibilidad del 68% y una especificidad del 84%. Las variables independientes en los análisis multivariados para predecir síndrome de Burnout fueron: CT (p<0,0001), OR (p<0,0001), TE (p<0,0001), total de CBO e índice de CBO (p<0,0001). Por cada incremento de un punto del total de antecedente (total CBO) se incrementa el riesgo de Síndrome de Burnout un 34 %; y si el índice CBO es ≥ a 21, se incrementa doce veces el riesgo de Síndrome de Burnout. De los médicos que presentaron SBO, el 84%, estuvo críticamente afectado por las consecuencias del SBO. Conclusiones: La utilización del Indice de Consecuencias de Burnout (l CBO) con un fin preventivo, podría evitar o retardar la aparición de SBO y disminuir el efecto del SB sobre la salud de los trabajadores.(AU)

Summary: Introduction: The burnout syndrome (SBO) is an inadequate response to chronic emotional stress due to high levels of stress at work, personal frustration and inappropriate attitudes of confrontation to conflict. Objectives: To determine the prevalence of SBO in a general hospital physicians highly complex in the city of Corrientes, identify associated factors and causal preventive set a flag to prevent or delay the development of BOS (l CBO). Materials and Methods: A cross sectional study was observational, which included 141 physicians. We used the Brief Questionnaire of Bernardo Moreno Burnout. The population was divided into five groups according to the service where they work: group 1 (surgery), group 2 (perinatology), group 3 (clinical), group 4 (emergency) and group 5 (various). ROC curve was constructed and determined a cutoff to predict SBO. We performed a univariate and multivariate three. Results: The prevalence of SBO was 44% (n = 62). Mean age was 49.9 ± 9.1 years. The overall cutoff CBO ≥ 21 had a sensitivity of 68% and a specificity of 84%. The independent variables in the multivariate analyzes to predict burnout were: CT (p <0.0001), OR (p <0.0001), TE (p <0.0001), and total CBO, CBO index (p <0.0001). For every one-point increase of the total background (total CBO) increases the risk of burnout syndrome by 34%, and if the index is ≥ 21 CBO, twelve times increases the risk of burnout syndrome. Of the doctors who had SBO, 84%, was critically affected by the consequences of SBO.Conclusions: The use of the Consequences of Burnout Index (l CBO) with a preventive purpose, could prevent or delay the onset of SBO and lessen the effect of SBO on the health of workers.(AU)

El sufrimiento mental en el trabajo: burnout en médicos de un hospital de Alta Complejidad, Corrientes / Mental suffering at work: burnout in doctors hospital High Complexity, Corrientes

Introducción: El síndrome de Burnout (SBO) es una respuesta inadecuada a un estrés emocional crónico consecuencia de elevados niveles de tensión en el trabajo, frustración personal y actitudes inadecuadas de enfrentamiento a situaciones conflictivas. Objetivos: determinar la prevalencia de SBO en médicos de un hospital general de alta complejidad de la ciudad de Corrientes; identificar factores asociados y causales; establecer un indicador preventivo para evitar o retardar el desarrollo de SBO (l CBO). Materiales y Métodos: se realizó un estudio transversal, observacional, que incluyo a 141 médicos. Se utilizó el Cuestionario Breve de Burnout de Bernardo Moreno. La población fue dividida en cinco grupos según el servicio donde se desempeñan: grupo 1 (quirófano), grupo 2 (perinatología), grupo 3 (clínica), grupo 4 (urgencias) y grupo 5 (varios). Se construyo una curva ROC y se determinó un punto de corte para predecir SBO. Se realizó un análisis univariado y tres multivariados. Resultados: la prevalencia de SBO fue del 44% (n=62). La edad media fue 49.9±9.1 años. El punto de corte de total CBO ≥ 21, tuvo una sensibilidad del 68% y una especificidad del 84%. Las variables independientes en los análisis multivariados para predecir síndrome de Burnout fueron: CT (p<0,0001), OR (p<0,0001), TE (p<0,0001), total de CBO e índice de CBO (p<0,0001). Por cada incremento de un punto del total de antecedente (total CBO) se incrementa el riesgo de Síndrome de Burnout un 34 %; y si el índice CBO es ≥ a 21, se incrementa doce veces el riesgo de Síndrome de Burnout. De los médicos que presentaron SBO, el 84%, estuvo críticamente afectado por las consecuencias del SBO. Conclusiones: La utilización del Índice de Consecuencias de Burnout (l CBO) con un fin preventivo, podría evitar o retardar la aparición de SBO y disminuir el efecto del SB sobre la salud de los trabajadores.

Summary: Introduction: The burnout syndrome (SBO) is an inadequate response to chronic emotional stress due to high levels of stress at work, personal frustration and inappropriate attitudes of confrontation to conflict. Objectives: To determine the prevalence of SBO in a general hospital physicians highly complex in the city of Corrientes, identify associated factors and causal preventive set a flag to prevent or delay the development of BOS (l CBO). Materials and Methods: A cross sectional study was observational, which included 141 physicians. We used the Brief Questionnaire of Bernardo Moreno Burnout. The population was divided into five groups according to the service where they work: group 1 (surgery), group 2 (perinatology), group 3 (clinical), group 4 (emergency) and group 5 (various). ROC curve was constructed and determined a cutoff to predict SBO. We performed a univariate and multivariate three. Results: The prevalence of SBO was 44% (n = 62). Mean age was 49.9 ± 9.1 years. The overall cutoff CBO ≥ 21 had a sensitivity of 68% and a specificity of 84%. The independent variables in the multivariate analyzes to predict burnout were: CT (p <0.0001), OR (p <0.0001), TE (p <0.0001), and total CBO, CBO index (p <0.0001). For every one-point increase of the total background (total CBO) increases the risk of burnout syndrome by 34%, and if the index is ≥ 21 CBO, twelve times increases the risk of burnout syndrome. Of the doctors who had SBO, 84%, was critically affected by the consequences of SBO.Conclusions: The use of the Consequences of Burnout Index (l CBO) with a preventive purpose, could prevent or delay the onset of SBO and lessen the effect of SBO on the health of workers.

Increased levels of cardiac troponin-T in outpatients with heart failure and preserved systolic function are related to adverse clinical findings and outcome.

BACKGROUND: The implications of increased levels of cardiac troponin T in congestive heart failure with preserved systolic function have been poorly evaluated. We hypothesized that its presence might be related to disease severity and prognosis in this setting. METHODS: Clinical, echocardiographic, 6-min walking test and laboratory data were prospectively obtained in 69 congestive heart failure outpatients with ejection fraction > or = 40%. Serial blood samples were assayed for cardiac troponin T with a third-generation immunoassay and values > or = 0.02 ng/ml were considered abnormal. RESULTS: Abnormal cardiac troponin T levels in at least one sample were found in 27 patients (39%, group 1). These patients were older (71.7 +/- 11 vs. 63 +/- 12.4 years, P = 0.002); more frequently hospitalized during the previous year (63 vs. 26.2%, P = 0.003), had lower systolic blood pressure (129.3 +/- 19.6 vs. 140.4 +/- 23.5 mmHg, P = 0.04), but had similar proportion of ischemic etiology (55.6 vs. 42.9%, P = 0.21) than those with normal cardiac troponin T (group 2). In groups 1 and 2, the functional class was 2.8 +/- 0.8 and 2.1 +/- 0.9 (P = 0.03), and the distance covered in 6 min was 339 +/- 100 and 386 +/- 103 m (P = 0.05), respectively. In groups 1 and 2, the 18-month congestive heart failure hospitalization-free survival was 22 and 87%, respectively (log-rank test P = 0.0003). In a Cox-proportional hazard model, functional class III-IV (hazard ratio = 5.21, 95% confidence interval: 1.43-18.96) and myocardial injury (hazard ratio = 5.51, confidence interval: 1.58-19.24) were independently associated with prognosis. CONCLUSION: Increased levels of cardiac troponin T were detected in one out of three congestive heart failure outpatients with preserved systolic function and correlated with clinical measures of disease severity and poor outcome. These findings suggest a link between ongoing myocardial injury and progressive impairment in congestive heart failure despite preserved systolic function.

[Clinical characteristics and long-term outcome in patients with heart failure complicating acute myocardial infarction]. / Características clínicas y evolución a largo plazo de pacientes con insuficiencia cardíaca como complicación del infarto agudo de miocardio.

INTRODUCTION AND OBJECTIVES: To evaluate the clinical characteristics and prognosis of heart failure (HF) development in patients hospitalized for acute myocardial infarction (AMI). PATIENTS AND METHOD: Between May 1990 and March 2000, 836 consecutive patients were admitted with a diagnosis of AMI within 24 h of symptom onset. HF was defined as the presence of rales and a third heart sound with gallop, and evidence of pulmonary congestion on chest x-ray. It was diagnosed in 263 subjects (31.5%). RESULTS: The mean age of patients with HF (group 1) was 63.4 (11.4) years compared with 59.9 (11.6) years in those without HF (group 2) (P<.01). There were differences between groups 1 and 2 in history of diabetes (36% vs 20%; P<.001) or previous HF (9.2% vs 1.1%; P<.001). The reperfusion strategy used in patients with Q-wave infarction, with or without HF, was primary angioplasty in 15% and 14%, respectively (P=.81), and thrombolytic agents in 28% and 37%, respectively (P=.013). Patients with HF were more likely to develop recurrent angina (26.8% vs 19.6%; P=.02), pericarditis (17.5% vs 6.3%; P<.001), and atrial fibrillation (12.3% vs 5.1%; P<.01). In-hospital mortality in groups 1 and 2 was 15.6% and 2.3% (P<.001), respectively, and 10-year survival was 10% and 30%, respectively (P<.001). The variables associated with mortality were: age (HR=1.022; P<.001), hyperglycemia (HR=1.748 per 1.0-g/L increase; P<.001), leukocytosis (HR=1.035 per 1000-cell/.L increase; P<.001), and HF (HR=1.308; P=.028). CONCLUSIONS: AMI is still frequently complicated by HF, which increases short- and long-term morbidity and mortality. Heart failure, age, hyperglycemia, and leukocytosis at admission were independent predictors of mortality during follow-up.

Características clínicas y evolución a largo plazo de pacientes con insuficiencia cardíaca como complicación del infarto agudo de miocardio / Clinical characteristics and long-term outcome in patients with heart failure complicating acute myocardial infarction

Introducción y objetivos. Evaluar las características clínico-evolutivas y el pronóstico a largo plazo del desarrollo de insuficiencia cardíaca (IC) en pacientes hospitalizados por un infarto agudo de miocardio (IAM). Pacientes y método. Entre mayo de 1990 y marzo de 2000 se ingresó a 836 pacientes consecutivos con IAM dentro de las 24 h de evolución. La IC definida por presencia de estertores, tercer ruido y signos de congestión pulmonar en la radiografía de tórax se diagnosticó en 263 sujetos (31,5%). Resultados. La edad media de los pacientes con IC (grupo 1) y sin IC (grupo 2) fue de 63,4 ± 11,4 frente a 59,9 ± 11,6 años (p < 0,01). Hubo diferencias en ambos grupos en los antecedentes de diabetes (36 y 20%; p < 0,001) e IC previa (9,2 y 1,1%; p < 0,001). La reperfusión utilizada en los pacientes con infarto con ondas Q, con y sin IC, fue la angioplastia primaria (el 15 frente al 14%; p = 0,81) y la administración de trombolíticos (el 28 frente al 37%; p = 0,013). Una mayor proporción de sujetos con IC evolucionaron con angina postinfarto (el 26,8 y el 19,6%; p = 0,02), pericarditis (el 17 y el 6,3%; p < 0,001) y fibrilación auricular (el 12,3 y el 5,1%; p < 0,01). La mortalidad hospitalaria en los grupos 1 y 2 fue del 15,6 y del 2,3% (p < 0,001), y la supervivencia a 10 años fue del 10 y del 30%, respectivamente (p < 0,001). Las variables asociadas a la mortalidad en el seguimiento fueron la edad (harzard ratio [HR] = 1,022; p < 0,001), la glucemia (incremento de 1,0 g/l: HR = 1,748; p < 0,001), la leucocitosis (aumento de 1.000 células/μl; HR = 1,035; p < 0,001) y la IC (HR = 1,308; p = 0,028) Conclusiones. El fallo cardíaco continúa siendo una complicación frecuente en el IAM y se asoció a una elevada morbimortalidad hospitalaria y tardía. La IC, la edad avanzada, la glucemia y la leucocitosis en el momento del ingreso fueron marcadores independientes de mortalidad tardía

Introduction and objectives. To evaluate the clinical characteristics and prognosis of heart failure (HF) development in patients hospitalized for acute myocardial infarction (AMI). Patients and method. Between May 1990 and March 2000, 836 consecutive patients were admitted with a diagnosis of AMI within 24 h of symptom onset. HF was defined as the presence of rales and a third heart sound with gallop, and evidence of pulmonary congestion on chest x-ray. It was diagnosed in 263 subjects (31.5%). Results. The mean age of patients with HF (group 1) was 63.4 (11.4) years compared with 59.9 (11.6) years in those without HF (group 2) (P<.01). There were differences between groups 1 and 2 in history of diabetes (36% vs 20%; P<.001) or previous HF (9.2% vs 1.1%; P<.001). The reperfusion strategy used in patients with Q-wave infarction, with or without HF, was primary angioplasty in 15% and 14%, respectively (P=.81), and thrombolytic agents in 28% and 37%, respectively (P=.013). Patients with HF were more likely to develop recurrent angina (26.8% vs 19.6%; P=.02), pericarditis (17.5% vs 6.3%; P<.001), and atrial fibrillation (12.3% vs 5.1%; P<.01). In-hospital mortality in groups 1 and 2 was 15.6% and 2.3% (P<.001), respectively, and 10-year survival was 10% and 30%, respectively (P<.001). The variables associated with mortality were: age (HR=1.022; P<.001), hyperglycemia (HR=1.748 per 1.0-g/L increase; P<.001), leukocytosis (HR=1.035 per 1000-cell/μL increase; P<.001), and HF (HR=1.308; P=.028).Conclusions. AMI is still frequently complicated by HF, which increases short- and long-term morbidity and mortality. Heart failure, age, hyperglycemia, and leukocytosis at admission were independent predictors of mortality during follow-up

Atorvastatin has an important acute anti-inflammatory effect in patients with acute coronary syndrome: results of a randomized, double-blind, placebo-controlled study.

BACKGROUND: C-reactive protein (CRP) levels are associated with cardiovascular risk. We assessed the hypothesis that atorvastatin might have anti-inflammatory effects in acute coronary syndromes (ACS) as shown by CRP reduction. METHODS: This study was a prospective, randomized, double-blind, placebo-controlled study of 90 consecutive patients admitted within 48 hours of onset of ACS with CRP levels > or =1.4 mg/dL. Patients were assigned to atorvastatin 40 mg daily or placebo over 30 days. C-reactive protein levels, lipid profiles, serum fibrinogen, white cell count, and erythrocyte sedimentation rate were measured at entry, hospital discharge, and 1 month later. RESULTS: Baseline clinical characteristics did not differ between atorvastatin and placebo groups (mean age 59.3 +/- 13.4 vs 61.1 +/- 11.5, P = ns); myocardial infarction 52.3% versus 67.4% ( P = ns). In both groups, median baseline CRP levels were comparable (5.97 +/- 6.2 vs 4.64 +/- 4.2 mg/dL, P = ns). C-reactive protein levels were lower in the atorvastatin group versus control group at discharge (1.68 +/- 1.65 vs 4.12 +/- 4.18 mg/dL) and at 30 days (0.50 +/- 0.71 vs 2.91 +/- 2.68 mg/dL, both P < .0001). C-reactive protein levels significantly decreased from baseline to discharge and 1 month later in placebo and atorvastatin groups (both P < .0001); however, the reduction was greater in the atorvastatin group (62% vs 11% at discharge [P < .0001]; 84% vs 30% at 1 month [P < .0001]). In addition, atorvastatin was associated with a reduction in total and low-density lipoprotein cholesterol and erythrocyte sedimentation rate at discharge and at 30 days (P < .0001 for all comparisons). No correlation was found between changes in CRP and cholesterol levels. CONCLUSIONS: C-reactive protein levels in ACS were rapidly reduced with atorvastatin. These data provide evidence that statins have fast and early anti-inflammatory effects in addition to lipid-lowering effects in ACS.

Ongoing myocardial injury in stable severe heart failure: value of cardiac troponin T monitoring for high-risk patient identification.

BACKGROUND: The progression of chronic heart failure (CHF) is related to ongoing myocyte loss, which can be detected by cardiac troponin T (cTnT). We examined the prevalence and prognostic value of increased cTnT concentrations in serial blood specimens from patients with severe CHF. METHODS AND RESULTS: Clinical, echocardiographic, and 6-minute walk test data were collected prospectively at baseline and at 1 year in 115 outpatients (mean age, 61+/-11 years; 75% men; 62% coronary heart disease) with CHF and a left ventricular ejection fraction <40%. Blood samples were collected at baseline and at 3, 6, and 12 months of follow-up. cTnT concentrations > or =0.02 ng/mL were considered abnormal, and a Tn index (highest cTnT measurement/0.02 ng/mL) was calculated. In 62 patients (54%), cTnT was consistently <0.02 ng/mL (group 1); 28 (24%) had a single abnormal cTnT result (group 2); and 25 (22%) had > or =2 abnormal cTnT results (group 3). At 18 months, CHF hospitalization-free survival was 63%, 46%, and 17%, respectively (P=0.0001). In a Cox proportional-hazards model, hospitalization for worsening CHF in the previous year (HR=2.1; 95% CI, 1.1 to 4.1), functional class III-IV (HR=2.3; 95% CI, 1.1 to 4.6), and number of abnormal cTnT samples (HR=1.6; 95% CI, 1.1 to 2.4) were independently associated with prognosis. A cTnT rise of 0.020 ng/mL in any sample was associated with an excess of 9% (95% CI, 1% to 18%) in the incidence of combined end point. CONCLUSIONS: Abnormal cTnT concentrations were detected in >50% of outpatients with advanced CHF. This ongoing myocardial necrosis was a strong predictor of worsening CHF, suggesting a role of cTnT-based monitoring to identify high-risk patients.

High levels of troponin T are associated with ventricular remodeling and adverse in-hospital outcome in heart failure.

BACKGROUND: Heart failure progression is associated with ventricular remodeling and ongoing myofibrillar degradation. We hypothesized that myocardial damage, detected by high levels of troponin T, would correlate with echocardiographic measurements of left ventricular remodeling and worse in-hospital course in decompensated heart failure. MATERIAL/METHODS: 159 patients with decompensated heart failure without acute coronary event were included. A troponin T value >0.2 ng/ml in samples taken 6, 12 or 24 hours after admission was considered abnormal. RESULTS: High troponin T levels were identified in 24 patients (15%) (Group 1). Mean age for group 1 was 65.9 vs. 63.7 years in patients with troponin T<0.2 (Group 2) (p=ns). Ischemic etiology in groups 1 and 2 was found in 58.3 and 38.5% (p=0.07). Two-dimensional echocardiograms in groups 1 and 2 revealed higher left ventricular diameters, diastolic (61.7+/-10 vs. 56.9+/-10.3 mm, p=0.041) as well as systolic (49.4+/-13.5 vs. 42.0+/-12.0 mm, p=0.012), and lower ejection fraction (30.1+/-14 vs. 39.0+/-17.7%, p=0.03). Incidence of combined end point of death or refractory heart failure was 20.8 and 3.7% in groups 1 and 2 (p=0.007; OR=6.8; CI95%=1.5-31.2). In a multiple regression model, a history of infarction and chronic obstructive pulmonary disease, tissue hypoperfusion, radiographic pulmonary edema, and high troponin T levels emerged as the independent predictors. CONCLUSIONS: High troponin T levels were found in 15% of patients with acute exacerbation of heart failure; this finding was independently associated with worse prognosis. Echocardiograms suggested that more severe ventricular remodeling is one subjacent mechanism related with biochemically detected myocardial injury in this setting.