La comunicación del error médico. Consecuencias éticas y médico-legales / Medical errors communication. Ethical and medicolegal issues

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El rechazo en las transfusiones de sangre y hemoderivados: criterios éticos, deontológicos y médico-legales / Refusal of blood or blood-products transfusions: ethical, deontological and medico-legal criteria

El rechazo de una transfusión de sangre y hemoderivados es una situación específica del derecho del paciente a rechazar cualquier tratamiento y se sustenta en el principio de autonomía que se ejerce a través del consentimiento. Este derecho se pone a prueba cuando se rechaza un tratamiento vital, lo que puede causar contrariedad y dudas en la actuación del profesional. En este artículo se revisan los principios éticos, las normas del Código de Deontología y los fundamentos médico-legales referentes al rechazo del tratamiento en que basar las recomendaciones posteriores, generales y específicas. Estas recomendaciones tienen por objetivo orientar la actuación del médico que debe respetar los derechos del paciente y actuar con seguridad jurídica (AU)

The refusal of a blood transfusion and blood products is a specific situation of the patient's right to refuse a treatment and is based on the principle of autonomy, exercised through consent. When a vital treatment is refused, it can cause disappointment and doubts to the professional. This article reviews the ethical principles, the Deontological Code and the medico-legal issues concerning the refusal of treatment, and proposes general and specific recommendations. The aim of these recommendations is to guide the conduct of the physicians who must respect the patient's rights and act with legal certainty (AU)

Case-control study of regular analgesic and nonsteroidal anti-inflammatory use and end-stage renal disease.

BACKGROUND: Studies on the association between the long-term use of aspirin and other analgesic and nonsteroidal anti-inflammatory drugs (NSAIDs) and end-stage renal disease (ESRD) have given conflicting results. In order to examine this association, a case-control study with incident cases of ESRD was carried out. METHODS: The cases were all patients entering the local dialysis program because of ESRD in the study area between June 1, 1995 and November 30, 1997. They were classified according to the underlying disease, which had presumably led them to ESRD. Controls were patients admitted to the same hospitals from where the cases arose, also matched by age and sex. Odds ratios were calculated using a conditional logistic model, including potential confounding factors, both for the whole study population and for the various underlying diseases. RESULTS: Five hundred and eighty-three cases and 1190 controls were included in the analysis. Long-term use of any analgesic was associated with an overall odds ratio of 1.22 (95% CI, 0.89-1.66). For specific groups of drugs, the risks were 1.56 (1.05-2.30) for aspirin, 1.03 (0.60-1.76) for pyrazolones, 0.80 (0.39-1.63) for paracetamol, and 0.94 (0.57-1.56) for nonaspirin NSAIDs. The risk of ESRD associated with aspirin was related to the cumulated dose and duration of use, and it was particularly high among the subset of patients with vascular nephropathy as underlying disease [2.35 (1.17-4.72)]. CONCLUSION: Our data indicate that long-term use of nonaspirin analgesic drugs and NSAIDs is not associated with an increased risk of ESRD. However, the chronic use of aspirin may increase the risk of ESRD.

[Baseline characteristics and determinants of outcome in a patient population admitted for heart failure to a general hospital]. / Características basales y determinantes de la evolución en pacientes ingresados por insuficiencia cardíaca en un hospital general.

INTRODUCTION AND OBJECTIVES: To assess baseline characteristics, management patterns, and clinical outcomes after 18 months in patients diagnosed as heart failure in a tertiary hospital in Catalonia, Spain. METHODS: The records of all 265 patients admitted to the Hospital General Vall d'Hebron from July through December 1998 with a diagnosis of heart failure who met study criteria were identified and analyzed. Patients were interviewed by telephone 18 months later. RESULTS: The mean age of the study population was 75 12 years, 42% were male, 19% were admitted for causes other than heart failure, and 62% had significant comorbidity. Ventricular function was assessed in 68% (preferentially patients with a better prognosis), and was considered normal in 41%. Angiotensin-converting enzyme inhibitors or angiotensin II antagonists were used in 54%, and beta-blockers in 4%. The 18-month mortality was 46% (77% cardiac mortality). Multivariate predictors of death were older age, severe or previous heart failure, and serious comorbidity. At 18 months, 69% of survivors were in functional classes I or II. CONCLUSIONS: 1) As in other geographic areas, patients in this study were an older population with poor survival; 2) local patterns of care definitely need improvement; 3) comorbidity is important for prognosis, and 4) a significant proportion of survivors enjoy an acceptable quality of life long after discharge.

Características basales y determinantes de la evolución en pacientes ingresados por insuficiencia cardíaca en un hospital general / Baseline characteristics and determinants of outcome in a patient population admitted for heart failure to a general hospital

Introducción y objetivos. Analizar las características basales, los patrones de manejo y los resultados clínicos a los 18 meses del ingreso en pacientes diagnosticados de insuficiencia cardíaca en un hospital terciario de Cataluña. Métodos. Se identificaron y analizaron las historias clínicas de los 256 pacientes ingresados en el Hospital General Vall d'Hebron desde julio a diciembre de 1998, diagnosticados de insuficiencia cardíaca y que cumplieran los criterios del estudio. Se entrevistó a los pacientes telefónicamente 18 meses después. Resultados. La edad media de los pacientes era de 75 ñ 12 años, el 42 por ciento correspondía a varones, el 19 por ciento había ingresado por enfermedades distintas de la insuficiencia cardíaca y el 62 por ciento tenía comorbilidad significativa. Se estudió la función ventricular en el 68 por ciento (básicamente en pacientes con mejor pronóstico), y se consideró normal en un 41 por ciento. Se administraron inhibidores de la enzima conversiva o antagonistas de la angiotensina II en un 54 por ciento y bloqueadores beta en un 4 por ciento. La mortalidad a los 18 meses fue del 46 por ciento, siendo de causa cardíaca en el 77 por ciento de éstos. Los predictores independientes de mortalidad fueron la edad avanzada, la insuficiencia cardíaca grave o antigua y la comorbilidad. A los 18 meses, un 69 por ciento de los supervivientes se hallaba en clase funcional I o II. Conclusiones. 1) Al igual que sucede en otras áreas geográficas, los pacientes de este estudio constituyen, como media, una población anciana y con pobre supervivencia; 2) los patrones de manejo registrados son claramente mejorables; 3) la comorbilidad afecta significativamente al pronóstico, y 4) la calidad de vida después del alta es aceptable en una llamativa proporción de supervivientes. (AU)