Optimisation of antithrombotic therapy in patients with acute coronary syndrome to reduce bleeding episodes.

AIM: The aim of the study was to evaluate the effectiveness of a multidisciplinary intervention to reduce the risk of bleeding associated with antithrombotic drugs in patients with acute coronary syndrome (ACS). METHODS: We designed a pre-post quasi-experimental intervention study using retrospective cohorts. The first cohort was analysed to detect correctable measures contributing to bleeding (PRE: January-July 2010). Second, a bundle of interventions was implemented and third, a second cohort of patients was evaluated to investigate the impact of our measures in bleeding reduction (POST: September 2011-February 2012). RESULTS: A total of 677 patients were included (377 in PRE and 300 in POST). The bundle of interventions was: Overdose avoidance measures: the percentage of patients overdosed was reduced by 66.3% (p < 0.001). Institutional protocol update to include the latest recommendations regarding bleeding prevention: In POST, the percentage of patients treated with fondaparinux increased (2.4% vs. 50.7%; p < 0.001). In PRE, 11 patients were treated with the combination of abciximab and bivalirudin; whereas in POST, only one patient received the combination (p = 0.016). Mandatory measurement of body weight: the percentage of patients with unknown body weight was reduced by 35% (p = 0.0001). In POST, the total bleeding rate was reduced by 29.2% (31.6% in PRE vs. 22.4%, p < 0.05, OR: 0.62; 95% CI: 0.44-0.88). It was necessary to implement the interventions in 11 patients to prevent one bleeding episode (95% CI: 7-39). CONCLUSION: The multidisciplinary programme has been effective in reducing bleeding episodes. The interventions were effective in reducing antithrombotic drugs overdosage, incorporating the use of fondaparinux to the NSTE-ACS therapeutic arsenal, limiting the use of bivalirudin with abciximab and obtaining body weight for most patients.

Validation of a method for recording pharmaceutical interventions.

WHAT IS KNOWN AND OBJECTIVE: The validation of a method for recording pharmaceutical interventions measures the instrument's ability to provide consistent values when the same analysis is performed several times. Our aim was to validate the inter-rater reliability of the method used to record pharmaceutical interventions in our hospital. METHODS: We recorded interventions in a database, entering variables related to the patient, treatment and impact of the recommendation. We also recorded the type, cause and clinical significance of the negative outcome associated with use of the medicinal product (NOM). Twenty interventions performed during a 3-year study period (2007-2009) were randomly tested for consistency to analyse the kappa (κ) coefficient statistic of the recommendations as coded by nine senior and junior clinical pharmacists. RESULTS AND DISCUSSION: There were 87·8% global consistency for NOM cause, 66·1% for intervention impact and 95·0% for NOM type. Agreement was substantial for 'intervention reasons', with a κ value of 0·74 (95%CI 0·61-0·87), fair for 'intervention impact', with a κ value of 0·24 (95%CI 0·15-0·32) and excellent for 'NOM type', with a κ value of 0·87 (95%CI 0·71-1·00), respectively. Our results are globally good, especially with regard to the analysis of intervention reasons and NOM type, which matches other authors' findings. Furthermore, our validation method is suitable for recording and considering the impact of pharmaceutical interventions. WHAT IS NEW AND CONCLUSION: We describe a systematic method for clinical pharmacists to record their activities and assess their value. This methodology should help in the development of clinical pharmacy in Spain and should be translatable to other settings.

[Drug-related interventions made through a computerized prescription order entry system in an Internal Medicine unit]. / Intervenciones farmacoterapéuticas realizadas mediante un programa de prescripción electrónica en una unidad de medicina interna.

INTRODUCTION: The objective of this article is to describe the drug-related interventions made in the prescriptions with a computerized order entry system and to determine their frequency and clinical relevance in order to propose improvement actions. MATERIAL AND METHOD: Observational descriptive study. Drug-related interventions made in the inpatient's prescriptions of an Internal Medicine unit from January to May of 2007 were analyzed and recorded. The frequency of the intervention causes and of the drugs involved was determined.The clinical significance and impact of the recommendations were also determined. RESULTS: A total of 441 interventions were recorded, 0.73 per patient. The most frequent was the proposal of intravenous to oral conversion (45%), mainly with acetaminophen (63%) and protons pump inhibitors (24%). This was followed by replacement of drugs not included in the guide (15% of interventions), mainly involving cardiovascular and central nervous system drugs (23% each one). Educational actions proposed included a campaign to promote intravenous to oral conversion and a program involving therapeutic equivalent replacement. The most clinically significant interventions were due to dosage errors, therapeutic duplicities, off label medications and adverse events. A proposal was made to include a new module in the medical order entry system that alerts on the established maximum doses for each drug, and new protocols for the treatment of certain conditions. Sixty percent of the interventions achieved an improvement in efficiency. DISCUSSION: We conclude that drug therapy intervention analysis can identify items that can be improved, set educational actions for physicians and new protocols for certain conditions. Innovative actions can be introduced into the medical order entry system in order to improve drug safety.

Intervenciones farmacoterapéuticas realizadas mediante un programa de prescripción electrónica en una unidad de medicina interna / Drug-related interventions made through a computerized prescription order entry system in an Internal Medicine Unit

Introducción: El objetivo de este trabajo es describir las intervenciones farmacoterapéuticas realizadas en las prescripciones, mediante un programa de prescripción electrónica, y determinar la frecuencia y la relevancia clínica para proponer acciones de mejora. Material y método: Se trata de un estudio descriptivo observacional. Hemos analizado y registrado las intervenciones farmacoterapéuticas realizadas en los pacientes ingresados en una unidad de medicina interna entre enero y mayo de 2007, y determinado la frecuencia de los motivos de intervención y fármacos, la significación clínica y el impacto de las recomendaciones. Resultados: Se han realizado 441 intervenciones, 0,73/paciente. La más frecuente fue la propuesta de secuenciación de la terapia (45%), fundamentalmente con paracetamol (63%) e inhibidores de la bomba de protones (24%). Después, la sustitución de medicamentos no incluidos en la guía (15%), los grupos mayoritarios: cardiovascular y sistema nervioso central (23% ambos). Las acciones formativas propuestas fueron una campaña para promocionar la terapia secuencial y un programa de equivalentes terapéuticos. Las intervenciones clínicamente más significativas fueron motivadas por errores de dosificación, duplicidades, medicamentos sin indicación y reacciones adversas. Se ha propuesto introducir en el programa de prescripción un módulo de alerta de dosis máximas y nuevos protocolos de patologías. El 60% de las intervenciones consiguieron mejorar la eficiencia. Discusión: Concluimos que el análisis de las intervenciones farmacoterapéuticas realizadas mediante un programa de prescripción electrónica permite identificar actuaciones dirigidas a médicos y patologías para protocolizar; así como posibilidades de innovación en el programa para aumentar la seguridad del tratamiento (AU)

Introduction: The objective of this article is to describe the drug-related interventions made in the prescriptions with a computerized order entry system and to determine their frequency and clinical relevance in order to propose improvement actions. Material and method: Observational descriptive study. Drug-related interventions made in the inpatient's prescriptions of an Internal Medicine unit from January to May of 2007 were analyzed and recorded. The frequency of the intervention causes and of the drugs involved was determined. The clinical significance and impact of the recommendations were also determined. Results: A total of 441 interventions were recorded, 0.73 per patient. The most frequent was the proposal of intravenous to oral conversion (45%), mainly with acetaminophen (63%) and protons pump inhibitors (24%). This was followed by replacement of drugs not included in the guide (15% of interventions), mainly involving cardiovascular and central nervous system drugs (23% each one). Educational actions proposed included a campaign to promote intravenous to oral conversion and a program involving therapeutic equivalent replacement. The most clinically significant interventions were due to dosage errors, therapeutic duplicities, off label medications and adverse events. A proposal was made to include a new module in the medical order entry system that alerts on the established maximum doses for each drug, and new protocols for the treatment of certain conditions. Sixty percent of the interventions achieved an improvement in efficiency. Discussion: We conclude that drug therapy intervention analysis can identify items that can be improved, set educational actions for physicians and new protocols for certain conditions. Innovative actions can be introduced into the medical order entry system in order to improve drug safety (AU)

Hemorragia postparto / Postpartum haemorrhage

La hemorragia postparto es una de las complicacionesobstétricas más temidas y es una de las tresprimeras causas de mortalidad materna en el mundo.Universalmente se define como la pérdida hemática superiora 500 ml tras un parto vaginal o a 1.000 ml trasuna cesárea. La hemorragia postparto precoz (HPP) esaquella que ocurre durante las primeras 24 horas trasel parto y es generalmente la más grave. Las causas deHPP incluyen atonía uterina, traumas/laceraciones, retenciónde productos de la concepción y alteracionesde la coagulación, siendo la más frecuente la atonía. Eldiagnóstico es clínico y el tratamiento ha de abarcarunas medidas generales de soporte vital y otras másespecíficas de carácter etiológico. Afortunadamente, espotencialmente evitable en la mayoría de los casos sise sigue una adecuada estrategia de prevención activay sistemática en la fase de alumbramiento de todos los partos(AU)

Postpartum haemorrhage is one of the most dreadedobstetric complications and one of the three maincauses of maternal mortality in the world. It is universallydefined as haematic loss above 500 ml followinga vaginal delivery or above 1,000 ml following a caesarean.An early postpartum haemorrhage (EPH) is onethat occurs during the first 24 hours following deliveryand is generally the most serious. The causes of EPHinclude uterine atony, trauma/lacerations, retention ofproducts of conception and alterations of coagulation,with atony being the most frequent. Diagnose is clinicaland treatment must include general life support measuresand other more specific measures of an etiologicalcharacter. Fortunately, in the majority of cases it is potentiallyavoidable if an adequate strategy of active andsystematic prevention is followed in the delivery phaseof all labors(AU)

[Postpartum haemorrhage]. / Hemorragia postparto.

Postpartum haemorrhage is one of the most dreaded obstetric complications and one of the three main causes of maternal mortality in the world. It is universally defined as haematic loss above 500 ml following a vaginal delivery or above 1,000 ml following a caesarean. An early postpartum haemorrhage (EPH) is one that occurs during the first 24 hours following delivery and is generally the most serious. The causes of EPH include uterine atony, trauma/lacerations, retention of products of conception and alterations of coagulation, with atony being the most frequent. Diagnose is clinical and treatment must include general life support measures and other more specific measures of an etiological character. Fortunately, in the majority of cases it is potentially avoidable if an adequate strategy of active and systematic prevention is followed in the delivery phase of all labors.

Pólipo endometrial metastásico de adenocarcinoma de colon tratado con análogos de la LHRH / Endometrial polyp with metastases from an adenocarcinoma of the colon, treated with LHRH analogs

Se presenta el caso de una paciente diagnosticada de metástasis peritoneales múltiples por adenocarcinoma de colon intervenido 2 años antes, y un pólipo endometrial metastatizado por el mismo tumor. Después de realizarle laparotomía exploradora y legrado diagnóstico, y debido a que el pólipo le provocaba metrorragias anemizantes, se inició tratamiento paliativo con análogos de la LHRH y quimioterapia, con lo que cedió la hemorragia. Casi 3 años después, la paciente continúa con buena calidad de vida. Se destaca la buena respuesta al tratamiento con análogos de la LHRH y a propósito del caso se revisa la bibliografía existente (AU)

[Error detection in the administration of antiretroviral therapy to out-patients]. / Detección de errores en la administración del tratamiento antirretroviral en pacientes externos.

OBJECTIVE: To describe medication errors in the administration of antiretroviral drugs in HIV patients involved in a pharmaceutical care program. METHODS: A retrospective review has been carried out on pharmaceutical care records for HIV patients who picked up medication at the Hospital Pharmacy Service between July 1999 and April 2002. Medication errors, median time to error detection and percentage of patients with written information supplied were measured. Medication errors were classified according to the terminology and the taxonomy of the Spanish Ruiz-Jarabo Group 2002. RESULTS: 513 patients' pharmaceutical care records were analysed (68% of total HIV outpatients). Forty medication errors were recorded (0.27 errors/100 patients dispensed per month). The median time to error detection was 35.5 days. Written information was supplied in 63% of the cases. Errors reached patients but did not cause any damage in most cases. Incorrect doses was the most frequent type of error detected, followed by food and drug interaction. CONCLUSIONS: Pharmaceutical care programs allow us to detect drug administration errors. The frequency of monitoring visits may influence time to error detection.

Adenocarcinoma renal de células claras que debuta con metástasis vaginal / Clear cell kidney adenocarcinoma presented with vaginal metastasis

- Propósito: El Adenocarcinoma de Células Claras puede tener origen en diversos y distintos órganos pudiendo metastatizar en vagina, principalmente por vía linfática, presentando un pronóstico malo de supervivencia1.- Material y métodos: se presenta un caso clínico de una masa vaginal como forma de debut de un Adenocarcinoma Renal.- Resultados: ante una masa vaginal el diagnóstico diferencial debe incluir en primer lugar la patología local, pero no debe descartarse la patología a distancia 5.- Conclusiones: Las metástasis vaginales, al ser muy infrecuentes, son diagnósticos de exclusión en el que debemos incluir patología local y patología a distancia, siempre orientados por la Anatomía patológica del tumor (AU)

Papiloma intraductal en mama ectópica localizada en vulva / Intraductal papilloma in an ectopic breast localized in the vulva

Sobre la cresta láctea, inicio de la organogénesis de la mama, pueden producirse alteraciones del desarrollo. Destaca por su frecuencia la polimastia, caracterizada por el aumento del número de mamas morfológicamente completas o tan sólo de tejido glandular. Aunque su localización más frecuente es la axila pueden aparecer en cualquier sitio de la "cresta láctea" (línea axila- vulva); están expuestas a influjos hormonales y sobre ellas puede asentar cualquier tipo de patología mamaria. Presentamos el caso clínico de una paciente de 33 años, con antecedentes familiares de cáncer de mama, que presentaba un nódulo vulvar sintomático, cuyo estudio histológico reveló que se trataba de un papiloma intraductal asentado, probablemente, sobre tejido mamario. Sólo por motivos estéticos o ante la existencia de síntomas, sobretodo si se asocian a antecedentes familiares de cáncer de mama, está indicada la extirpación quirúrgica del tejido mamario accesorio, ectópico o aberrante. (AU)