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Diagnostic errors have to be recognised as a possible adverse event inherent to clinical activity and incorporate them as another quality indicator. Different sources of information report their frequency, although they may still be underestimated. Contrary to what one could expect, in most cases, it does not occur in infrequent diseases. Causes can be complex and multifactorial, with individual cognitive aspects, as well as the health system. These errors can have an important clinical and socioeconomic impact. It is necessary to learn from diagnostic errors in order to develop an accurate and reliable system with a high standard of quality.

Resumen Debemos reconocer el error diagnostico como un episodio adverso posible e inherente al acto clinico, e incorporarlo con normalidad al resto de los indicadores de calidad asistencial. Por diferentes fuentes de informacion podemos conocer su frecuencia, aunque probablemente todavia esta subestimada. En contra de lo que se podria suponer, en la mayoria de los casos no acontece en enfermedades infrecuentes. Sus causas suelen ser complejas y multifactoriales, con aspectos tanto cognitivos individuales como del sistema. Estos errores pueden tener un gran impacto clinico y socioeconomico. Es necesario aprender de los errores diagnosticos para desarrollar un sistema seguro, propio de una cultura de calidad.

Resumen: Antecedentes: Poder aprender de sus errores supone para los clínicos un elemento de gran interés. Esta función la plantea la retroinformación clínica en sentido formativo (feedback), reconocida como un elemento útil en la mejora de la calidad asistencial y la seguridad clínica. Objetivos: Describir nuestra experiencia en feedback formativo, analizando las características de los casos clínicos incorporados, así como la opinión de los profesionales que recibieron la formación. Material y métodos: Estudio descriptivo, que recoge la experiencia de un año, en la práctica de feedback formativo sobre incidentes clínicos. Se determinó: fuente de notificación, descripción del incidente e impacto clínico, mensajes clave y tipo de feedback (grupal y/o individual). Así mismo, se planteó una encuesta de opinión al grupo de facultativos. Resultados: Se incluyeron 27 casos, que suponen un 0,06% de las asistencias. Las fuentes de notificación fueron: el propio SUH en 19 (70,3%) casos, unidad de atención a la ciudadanía en 3 (11,1%), dirección de calidad en 2 (7,4%), unidad de admisiones en 2 (7,4%) y servicio de microbiología en uno (3,7%). Los casos correspondían en un 7,4% a aspectos de carácter diagnóstico, 40,7% terapéutico, y 55,5% de ambos. La encuesta a los profesionales, aunque con una participación del 36%, mostró unas valoraciones positivas en todos los aspectos planteados. Conclusiones: Incorporar el feedback formativo para los profesionales resulta factible, parece ser bien recibido y podría representar una herramienta útil en la mejora de la seguridad clínica. Abstract: Background: To learn from one's mistakes is an element of great interest for clinicians. This strategy is proposed as clinical feedback in a training sense, recognized as a useful element for the improvement of healthcare quality and clinical safety. Objectives: To describe our experience in training feedback, analysing the characteristics of the clinical cases included, as well as the opinion of the professionals who received the training. Material and methods: A descriptive study, which gathers the experience of one year in the practice of educational feedback on clinical incidents. Source of notification, description of the incident and clinical impact, key messages and type of feedback (individual and / or group level) were determined. In addition, an opinion survey was proposed to all the doctors. Results: 27 cases were included, which represent .06% of the total medical care provided. The sources of notification were the emergency department in 19 (70.3%) cases, citizenship unit 3 (11.1%), quality management 2 (7.4%), admissions unit 2 (7.4%) and microbiology department 1 (3.7%). Of the cases, 7.4% corresponded to aspects related to diagnosis, 40.7% to therapy, and 55.5% to both. The survey for professionals showed a predominance of positive assessments in all aspects raised, although participation was 36%. Conclusions: Incorporating training feedback for professionals is feasible, seems to be well accepted and could prove a useful tool for improving clinical safety. Palabras clave: Feedback formativo, Seguridad clínica, Urgencias, Keywords: Training feedback, Clinical safety, Emergency

Recent years have seen a range of measures deployed to curb crowding in hospital emergency departments, but as episodes of overcrowding continue to occur the discussion of causes and possible solutions remains open. The problem is universal, and efforts to revamp health care systems as a result of current socioeconomic circumstances have put emergency services in the spotlight. Consensus was recently achieved on criteria that define emergency department overcrowding. The causes are diverse and include both external factors and internal ones, in the form of attributes specific to a department. The factors that have the most impact, however, involve hospital organization, mainly the availability of beds and the difficulty of assigning them to emergency patients requiring admission. Crowding is associated with decreases in most health care quality indicators, as departments see increases in the number of patients waiting, the time until initial processing, and the time until a physician or nurse intervenes. Crowding is also associated with risk for more unsatisfactory clinical outcomes. This situation leads to dissatisfaction all around-of patients, families, and staff-as aspects such as dignity, comfort, and privacy deteriorate. Proposals to remedy the problem include assuring that the staff and structural resources of a facility meet minimum standards and are all working properly, facilitating access to complementary tests, and providing observation areas and short-stay units. The response of hospitals to the situation in emergency departments should include alternatives to conventional admission, through means for rapid diagnosis, day hospitals, and home hospitalization as well as by offering a clear response in cases where admission is needed, granting easier access to beds that are in fact available. For its part, the health system overall, should improve the care of patients with chronic diseases, so that fewer admissions are required. It is also essential to search for ways to bring the supply of necessary social and health care services more in step with demand.En los últimos años hemos asistido al despliegue de diferentes medidas de desarrollo de los SUH, pero a pesar de ello los episodios de saturación siguen sucediéndose y el debate en cuanto a sus causas y posibles soluciones sigue abierto. Se trata de un problema universal y en el momento actual las circunstancias socioeconómicas comportan un replanteamiento del sistema sanitario, en el que los SUH tendrán un papel crucial. Recientemente se han consensuado los criterios concretos que definen una situación de saturación en los SUH. Las causas de la saturación son diversas e implican aspectos tanto externos a los SUH como intrínsecos a la propia unidad. Pero los más determinantes son propios de la dinámica hospitalaria, fundamentalmente la dificultad en adjudicación de cama para ingreso y en su disponibilidad real. Esta saturación se asocia a un descenso de la mayoría de indicadores de calidad. Así mismo, se incrementan el número de pacientes que esperan ser atendidos, el tiempo de espera para el inicio de la asistencia y el tiempo de actuación médico-enfermería. Además conlleva un alto riesgo de peores resultados clínicos. Esta situación conduce a la insatisfacción de pacientes, familiares y personal sanitario y a deterioro de aspectos como la dignidad, la comodidad o la confidencialidad. Las propuestas de mejora pasan por asegurar unos mínimos recursos estructurales y de personal, y agilizar algunas exploraciones complementarias, así como implementar áreas de observación y unidades de corta estancia. La respuesta de los centros a los SUH debería incluir alternativas a la hospitalización convencional con dispositivos de diagnóstico rápido, hospitales de día y hospitalización domiciliaria, así como acciones de respuesta bien definidas a las necesidades de ingreso hospitalario, con agilización de la disponibilidad real de camas. El sistema sanitario por su parte debería mejorar el control de los pacientes crónicos para reducir las necesidades de ingreso, y adecuar la oferta a las necesidades reales de atención sociosanitaria.

Purpose To assess the correlation of procalcitonin (PCT), C-reactive protein (CRP), neopterin, mid-regional pro-atrial natriuretic peptide (MR-proANP), and mid-regional pro-adrenomedullin (MR-proADM) with severity risk scores: severe CAP (SCAP) and SMART-COP in patients with community-acquired pneumonia (CAP), as well as short term prognosis and to determine the correlation with mortality risk scores. Methods Eighty-five patients with a final diagnosis of pneumonia were consecutively included during a two month period. Epidemiological, clinical, microbiological, and radiological data were recorded. Patients were stratified according to the PSI, CURB-65, SCAP and SMART-COP. Complications were defined as respiratory failure/shock, need of ICU, and death. Plasma samples were collected at admission. Results MR-proANP and MR-proADM showed significantly higher levels in high risk SCAP group in comparison to low risk. When considering SMART-COP none of the biomarkers showed statistical differences. MR-proADM levels were high in patients with high risk of needing intensive respiratory or vasopressor support according to SMRT-CO. Neopterin and MR-proADM were significantly higher in patients that developed complications. PCT and MR-proADM showed significantly higher levels in cases of a definite bacterial diagnosis in comparison to probable bacterial, and unknown origin. MR-proANP and MR-proADM levels increased statistically according to PSI and CURB-65. Conclusions Biomarker levels are higher in pneumonia patients with a poorer prognosis according to SCAP and SMART-COP indexes, and to the development of complications.

Resumen Fundamento y objetivos Valorar la relacion entre algunas variables clinicas y analiticas, y la existencia de bacteriemia para establecer un modelo predictivo. Pacientes y metodo Se analizaron durante 2 meses los casos atendidos en Urgencias con muestras para hemocultivos. Se elaboro con el grupo de derivacion un modelo predictivo de bacteriemia y se valido en el grupo restante. Las variables significativas del analisis univariado se sometieron a regresion logistica y de esta se derivo una puntuacion. Se calculo la prevalencia de bacteriemia para cada puntuacion en ambos grupos. Se evaluo la calibracion del modelo por la prueba de Hosmer-Lemeshow, se calcularon las curvas de eficacia diagnostica y el rendimiento del modelo. Resultados Se incorporaron al estudio 412 casos, los hemocultivos fueron positivos en el 12,8 %. Las variables significativas en el analisis multivariado fueron un indice de Charlson superior o igual a 2 y una procalcitonina superior a 0,4 ng/ml. Con el sistema de puntuacion (1 y 2 puntos, respectivamente) se establecieron 4 grupos de probabilidad creciente de bacteriemia; del 0–35% en el grupo de derivacion y del 2,9–27,2% en el de validacion. En la curva de eficacia diagnostica, el area bajo la curva fue de 0,80 en el grupo de derivacion y de 0,74 en el de validacion. El modelo presento un valor predictivo negativo del 95,2% en el grupo de derivacion y del 95,3% en el de validacion. Conclusiones Se propone un modelo de prediccion con las variables indice de Charlson y procalcitonina que permite delimitar un grupo con muy baja probabilidad de bacteriemia.

Fundamento y objetivo Analizar la relacion entre motivo de consulta y error diagnostico, los mecanismos clinicos de este, y la trascendencia clinica del error, en pacientes atendidos en un area medica de urgencias. Pacientes y metodo Se analizan los ingresos en el area medica comparando los diagnosticos en urgencias y al alta para detectar los casos con error. Se compararon las variables edad, sexo, horario y motivo de consulta, estancia y mortalidad, entre los grupos con y sin error. Los casos con error diagnostico se analizaron para determinar los mecanismos del error y su trascendencia clinica. Resultados Se detectaron 42 casos (6,2%) con error diagnostico. No se encontraron diferencias significativas en cuanto a la distribucion de edad, sexo, horario, dias de estancia y mortalidad, pero si en cuanto a los diferentes motivos de consulta, siendo la fiebre la que presento una mayor y significativa frecuencia de error (p Conclusiones Los errores diagnosticos en urgencias son mas frecuentes en los pacientes que consultan por fiebre. Se producen mayoritariamente en relacion con una anamnesis sobre los sintomas actuales o exploracion fisica insuficientes, o con una interpretacion erronea de la radiologia. Aunque a menudo implican retrasos en el inicio de tratamientos especificos, no incrementan la estancia hospitalaria ni la mortalidad.

Overuse of hospital emergency rooms (HERs) is parallel to their controversy. To understand this problem, some concepts should be first clarified. In HERs, there are some intrinsic aspects which are directly related to the emergency itself and thus cannot be modified (intermittent patient flow, need to prioritize, difficulty to achieve a rapid diagnosis, influence of time on treatment, value of clinical follow up, patient's expectations, impact of HER on the overall hospital working dynamics). On the other hand, there are some extrinsic aspects which indeed are not related to HER itself but are rather historically associated with it (precarious structure, delay on admission, lack of privacy, inadequate triage of cases, lack of professionalization); these latter aspects may be potentially modified and should be reconsidered.

Sabado 1 Diciembre 2007. Volumen 129 - Numero 20 p. 770 - 772 Texto completo Descargar PDF Buscar en medline articulos de: Pere Tudela Josep Maria Modol Montserrat Gimenez Cristina Prat Blanca Vilaseca Jordi Tor Buscar: en Medicina Clinica en Vol. 129, Num. 20 Busqueda avanzada Originales breves Bacteriemia en pacientes no hospitalizados: tendencias evolutivas en los ultimos 10 anos Pere Tudelaa Josep Maria Modola Montserrat Gimenezb Cristina Pratb Blanca Vilasecac Jordi Tord aUnidad de Corta Estancia-Servicio de Urgencias. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. bServicio de Microbiologia. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. cUnidad de Corta Estancia-Servicio de Urgencias. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. dServicio de Medicina Interna. Hospital Germans Trias i Pujol. Badalona. Barcelona. Espana. Fundamento y objetivo: Conocer la incidencia anual de bacteriemia en pacientes no hospitalizados (BPNH), analizar sus caracteristicas clinicas y epidemiologicas, asi como sus tendencias evolutivas. Pacientes y metodo: Se analizo un periodo de 10 anos, durante el cual se contabilizaron el porcentaje de hemocultivos positivos y, de estos, el porcentaje de BPNH. Se recogieron los siguientes parametros: ano, mes, edad, sexo, diagnostico inicial, factores de riesgo para la bacteriemia, microorganismo, diagnostico final, concordancia entre ambos y necesidad de ingreso. Se clasificaron en: infeccion urinaria, respiratoria, abdominal, de cateter venoso (ICV), cutanea, endocarditis, bacteriemia sin focalidad aparente (BSFA) y un grupo miscelanea. Se compararon las variables edad, sexo, ano y mes entre los grupos con y sin diagnostico concordante. Resultados: Se registraron 283 episodios. El porcentaje de hemocultivos positivos se mantuvo constante, mientras que el de BPNH tendio a descender. El microorganismo mas frecuente fue Escherichia coli (56,5%), y los principales focos, el urinario (59,7%) y la BSFA (19,7%). Los diagnosticos inicial y final no eran concordantes en el 37,1% de los casos. Preciso ingreso el 30,3%. Se detecto infeccion urinaria en el 93,5% de los casos, ICV solo en el 6,2% y ninguna BSFA. La presencia de los principales factores de riesgo para la bacteriemia a lo largo de los anos mostro un descenso de la infeccion por el virus de la inmunodeficiencia humana, mientras que se advertia un ascenso de las enfermedades neoplasicas. Conclusiones: La BPNH, en nuestra experiencia, tiende a un descenso progresivo. La de origen urinario no parece preocupante, mientras que es mejorable la sospecha de ICV. La BSFA constituye el grupo mas preocupante y supone un reto diagnostico para el futuro

The aim of this study was to compare the clinical, biological, and radiologic features of presentation in the emergency ward of community-acquired pneumonia (CAP) by Legionella pneumophila (LP) and other community-acquired bacterial pneumonias to help in early diagnosis of CAP by LP. Three hundred ninety-two patients with CAP were studied prospectively in the emergency department of a 600-bed university hospital. Univariate and multivariate analyses were performed to compare epidemiologic and demographic data and clinical, analytical, and radiologic features of presentation in 48 patients with CAP by LP and 125 patients with CAP by other bacterial etiology (68 by Streptococcus pneumoniae, 41 by Chlamydia pneumoniae, 5 by Mycoplasma pneumoniae, 4 by Coxiella burnetii, 3 by Pseudomonas aeruginosa, 2 by Haemophilus influenzae, and 2 by Nocardia species. Univariate analysis showed that CAP by LP was more frequent in middle-aged, male healthy (but alcohol drinking) patients than CAP by other etiology. Moreover, the lack of response to previous beta-lactamic drugs, headache, diarrhea, severe hyponatremia, and elevation in serum creatine kinase (CK) levels on presentation were more frequent in CAP by LP, while cough, expectoration, and thoracic pain were more frequent in CAP by other bacterial etiology. However, multivariate analysis only confirmed these differences with respect to lack of underlying disease, diarrhea, and elevation in the CK level. We conclude that detailed analysis of features of presentation of CAP allows suspicion of Legionnaire's disease in the emergency department. The initiation of antibiotic treatment, including a macrolide, and the performance of rapid diagnostic techniques are mandatory in these cases.

Fundamento Conocer la concordancia diagnosticaentre urgencias y hospitalizacion, analizandoel indice de error, sus caracteristicasepidemiologicas y motivos fundamentales. Pacientes y metodo Se analizaron los ingresosen el area medica, estableciendo tres nivelesde concordancia: coincidente (A), sindromica(B) y erronea (C). Se compararon lasvariables edad, sexo, horario y estancia, enlos grupos A + B y C. En el grupo C se determinoel motivo fundamental del error. Resultados La concordancia fue nivel A enel 88,1%, B en el 7,3% y C en el 4,6%. Nohubo diferencias significativas en la distribucionde las variables analizadas. Los motivosde error mas frecuentes fueron una valoracionclinica insuficiente (50%) y la interpretacionde la radiografia de torax (28,6%). Conclusiones La concordancia diagnosticafue mayoritaria, con un indice de error inferioral 5%. No hallamos un perfil epidemiologiconi clinico caracteristico del error. Elmotivo mas frecuente de error fue una insuficientevaloracion clinica.

Fundamento Conocer la frecuencia con que se realizala puncion lumbar (PL) en urgencias y susindicaciones, asi como su rendimiento diagnosticoen la sospecha de infeccion del sistema nerviosocentral (ISNC). Pacientes y metodo Se analizaron las puncionespracticadas durante dos anos en un servicio de urgencias,comparando las caracteristicas clinicasde los casos en que la PL confirmo o no la sospechade infeccion. Se revisaron los casos de ISNCno sospechados en urgencias. Resultados En el 0,4% de las urgencias medicasse practico un PL. En el 76% la indicacion fuesospecha de ISNC, de las cuales se confirmaron el30%. Fiebre, cefalea, rigidez de nuca y antecedentesde otitis o sinusitis cronica fueron las variablesasociadas a ISNC. Un 11% de las ISNC nose sospecharon en urgencias, y de ellas el 80%tenian el antecedente de infeccion por el VIH. Conclusiones La PL se realiza frecuentemente enurgencias, fundamentalmente por sospecha deISNC, que se confirma en un tercio de los casos.La ISNC no sospechada en urgencias correspondemayoritariamente a meningitis subagudas en pacientescon infeccion por el VIH.

To evaluate the relationship between some clinical and analytical data and the presence of bacteremia in order to establish a clinical decision rule.All the patients with blood cultures obtained from the emergency room in a two months period were analyzed. Patients were randomly assigned to derivation or validation sets. A logistic regression of the significant values in the univariate analysis was performed and a score obtained. The prevalence of bacteraemia for every score was calculated. The diagnostic efficacy curves and the performance of the predictive model were calculated.412 patients were enrolled. The blood cultures were positive in 12.8% of them. The significant values in the univariate analysis were Charlson index ≥2 and PCT0.4ng/ml. Four groups of increasing risk of bacteraemia were designed, from 0 to 35% in the derivation set and from 2.9% to 27.2% in the validation set. In the diagnostic efficacy curve, the AUC was 0.8 in the derivation set and 0.74 in the validation set. The model presented a negative predictive value of 95.2% in the derivation set and 95.3% in the validation set.A model that includes Charlson index and PCT makes possible to define a group of patients with a very low risk of bacteremia.

To know the incidence of bacteremia in outpatients (BO), their clinical and epidemiological characteristics and evolution.We have analyzed the percentage of positive blood cultures and BO in a 10 year period. We have collected year, month, age, gender, first diagnosis, risk factors for bacteremia, microrganism, final diagnosis and diagnosis concordance. The bacteremia was classified by origin in: urinary tract infection, respiratory, abdominal, venous catheter (IVC), skin, endocarditis, bacteremia without an apparent focus (BWAF) and miscellaneous. We have compared the characteristics of the patients with and without diagnosis concordance.We have collected 283 episodes. The percentage of positive blood culture remained wi-thout changes and the percentage of BO tended to decrease. The most prevalent bacteria was Escherichia coli (56.5%) and the most frequent origin was urinary (59.7%) and BWAF (19.7%). There was no concordance between diagnoses in 37.1%. 30.3% of patients were admitted. Urinary tract infection was detected in 93.5% of the cases, IVC in 6.2% and BWAF in 0%. With regard to the risk factors of bacteremia, human immunodeficiency infection tended to decrease and neoplasm to increase during the study period.In our experience, BO tends to decrease. The management of urinary infection seems adequate, and IVC could be improved. The main challenge is the cases of BWAF.

To evaluate the usefulness of midregional pro-atrial natriuretic peptide (MR-proANP) measurement in the stratification of severity in community-acquired pneumonia.The population studied was three hundred patients admitted to Emergency Department of a tertiary university hospital presenting clinical signs of lower respiratory tract infection, a new infiltrate on the chest radiograph and a confirmed pneumonia by clinical evolution. Patients were stratified by the Pneumonia Severity Index (PSI), by CURB-65 score and by the development of complications. Serum samples were obtained at the moment of admission and prior to antibiotic therapy, and stored until analysis. MR-proANP was measured by B.R.A.H.M.S MR-proANP KRYPTOR.Serum levels of MR-proANP increased with the severity of pneumonia, according to PSI score and CURB-65 score. Median MR-proANP levels were significantly higher (p0.0001) in patients with high PSI risk class (IV-V) than in those with low PSI risk class (I-III). MR-proANP levels were also significantly higher (p=0.029) in those patients that developed complications or died. There was no association between MR-proANP and etiology of pneumonia and the radiographic extent.We can conclude that MR-proANP measurement was helpful for individual risk assessment in patients with pneumonia admitted to the emergency department.

RESUMO: A Legionella pneumophila (LP) é considerada em muitos estudos como uma das três causas mais comuns de pneumonia adquirida na comunidade (2,4) e a segunda causa em termos de gravidade.O principal objectivo do presente estudo realizado no Hospital da Universidade Autónoma de Barcelona, foi comparar os diferentes aspectos clínicos, biológicos e radiológicos da Pneumonia a Legionella pneumophilla e das outras Pneumonias adquiridas oa comunidade (PAC), de modo a auxiliar o diagnóstico precoce da pneumonia a LP.Foi realizado um estudo prospectivo de 392 doentes com PAC. Procedeu-se à análise comparativa dos aspectos epidemiológicos (hospitalizações ou viagens recentes, residência próximo de escavações ou trabalhos de constrção, contacto com animais, aves), demográficos (idade e sexo), clinicos (febre, tosse, expectoração, toracalgia, dispneia, cefaleias, confusão mental, dor aboominal, náuseas, vómitos, diarreia, artromialgias, dias de evolução, antibioterapia prévia, patologiaassociada), analiticos (leucocitose, natrémia­Na, creatina Kinase-CK, aspartato aminotransferase­AST) e radiológicos. Estes aspectos foram estudados em 48 doentes com PAC por LP e 125 doentes com PAC de outra etiologia (68 por Streptococcus pneumoniae, 41 por Clamydia pneumoniae, 5 por Mycoplasma pneumoniae, 4 por Coxiella burnetii, 3 por Pseudomonas aeruginosa, 2 por Haemophilus injluenzae e 2 por Nocardia).A análise unifactorial mostrou que a PAC por LP foi mais frequente hos doentes de meia idade, do sexo masculino, em saúde aparente, mas com hábitos alcoó1icos acentuados, relativamente aos doentes com PAC de outra etioçogia. Também a auseocia de resposta aos fármacos beta-lactamicos prévios, cefaleias, diarreia, hiponatrémia grave e a elevação dos níveis de creatina Kinase sérica (CK) foram mais frequentes na PAC por LP, enquanto que a tosse, expectoração e a toracalgia., foram mais frequeotes na pneumonia bacteriana de outra etiologia. Contudo, a análise multifactorial sómente confirmou estas diferenças relativamente à ausência de doença subjacente, diarreia e elevação dos niveis de CK. Concluiu-se que a anàlise detalbada do modo de apresentação da. PAC perrnite suspeitar a doença dos Legionários numa. unidade de emergência medica. O inicio de antibioterapia, incluindo urn macrólido e as técnicas que permitem urn diagnóstico rápido (isolamento no sangue, secreções brônquicas, urina) são mandatórias de modo a reduzir a morbilidade e mortalidade da doença. COMENTÁRIO: A Pneumonia a Legionella pneumophila é uma das pneumonias adquiridas na. comunidade mais frequentes(1,2,4,5,9), constituindo o terceiro agente etiológico a seguir ao Pneumococo e Mycoplasma. Esta pneumonia adquire por vezes formas graves, com morbilidade e mortalidade elevadas (1,3).Têm sido realizados diversos trabalhos prospectivos e retrospectivos (1,2,3,4,6,8), com o intuito de conhecer quais as principais caracteristicas epidemio1ógicas, clinicas e laboratoriais que permitem distinguir a pneumonia a LP das outras pneumonias da comunidade, de modo a obter um diagnóstico de presunção e uma terapêutica adequada tão precoces quanto possível.A transmissão ocorre por via aérea, habitualmente através da inalação de vaporcs que contêm o microrganismo. Apesar de oeste estudo não se ter encontrado um predominio sazonal, vários trabalhos o apontarn. embora variável de ano para ano(1,6).A pneumonia a LP como foi observado no presente trabalho, predomina em docntcs do sexo masculino (1), de meia-idade. Relativamcntc aos tactores de risco para infecção, o alcoolismo e hábitos tabagicos foram mais rrcquentes na pneumonia a LP (1), enquanto que nas pneumonias de outra etiologia predominararn os doentes com patologias associadas ou imunodeprimidos.Relativamente às manifestacções clínicas, a tosse, expectoração e toracalgia são mais frequentes nas pneumonias de outra etiologia, enquanto que as cefaleias, confusão mental e a diarreia predominam na pneumonia a LP, em que é frequente o envolvimento multissistémico (rim. figado e sistema nervoso) (1,9,10).Nos doentes com PAC a LP, os valores de hiponatrémia (37 U/L) e dos níveis de CK (>232 U/L) foram significativamente superiores aos obtidos nas PAC de outra etiologia, embora apenas nos valores de Natrémia e creatina Kinase as diferenças tenham sido estatisticamente significativas. Outros trabalhos têm rcferido que a encefalopatia, a hiponatrémia, a hematuria microscópica, as anomalias da função renal e hepática surgem com mais frequência na pneumonia a LP que noutras pneumonias (1).Não se encontraram diferenças radiológicas significativas em ambos os grupos de pneumonias adquiridas na comunidade (8), tal como verificado noutros trabalhos (1).Pode concluir-se que perante urn doente com urn quadro clinico sugestivo de Pneumonia grave adquirida na comunidade, há algumas características clínicas e laboratoriais que permitem urn diagnóstico de presunção de pneumonia a Legione/la pneumophila, sendo mandatório nestes casos (7) o inicio de terapêutica empírica com urn macrólido.Convém ser-se criterioso, permanecendo contudo dificil a decisão terapêutica dos doentes com pneumonia adquirida na comunidade. Se por urn lado se corre o risco de não tratar adequada e precocemente uma PAC aLP que pode ter uma cvolução grave, por outro lado, o uso sistematico de determinado grupo de farmacos sem indicação para tal, conduz ao perigo de aumcnto da resistencia antibiótica, como se tern verificado na última decada relativamente à eritrornicina (11). Palavras-chave: lnfecçõcs adquiridas na comunidade, Legionella pneumophila, Pneumonia, Bacteriana, Key-words: Community-acquired infections, Legionella pneumophila, Pncumonia, Bacterial

We evaluated the impact of the copper-silver ionization system in a hospital where hyperendemic nosocomial legionellosis and was present and all previous disinfection measures had failed. After implementation of the copper-silver ionization system, environmental colonization with Legionella species decreased significantly, and the incidence of nosocomial legionellosis decreased dramatically, from 2.45 to 0.18 cases per 1000 patient discharges.

We intended to analyze the relation between the main symptom at hospital admission and the diagnosis mistake, assessing the reasons and clinical implications.We analyzed hospitalized patients from the emergency room to the medical wards. We collected: age, sex, time, main symptom at admission, diagnosis at admission and final diagnosis, days of hospitalization and mortality. We established two groups: patients with a concordant diagnosis and patients with a wrong diagnosis, and we compared the characteristics of them. In each case of a wrong diagnosis, we analyzed the reason of the mistake and the clinical consequences.We found a wrong diagnosis in 42 (6.2%) cases. Fever, as main symptom at admission, had a significant higher rate of mistake than other symptoms. No differences were found in the other variables analyzed. Most frequently omitted diagnosis were infectious diseases, pulmonary embolism and heart failure. Main causes of mistake were a deficient clinical evaluation and X-ray interpretation. The mistake implied a delay in the specific treatment in 42.8% cases.Diagnostic mistakes in the emergency room are more frequent in patients attending with fever. They are mostly related to deficient clinical evaluation or wrong interpretation of X-ray findings. Although these mistakes usually lead to a delay in the treatment, no increase in the days of hospitalization or mortality is observed.

Overuse of hospital emergency rooms (HERs) is parallel to their controversy. To understand this problem, some concepts should be first clarified. In HERs, there are some intrinsic aspects which are directly related to the emergency itself and thus cannot be modified (intermittent patient flow, need to prioritize, difficulty to achieve a rapid diagnosis, influence of time on treatment, value of clinical follow up, patient's expectations, impact of HER on the overall hospital working dynamics). On the other hand, there are some extrinsic aspects which indeed are not related to HER itself but are rather historically associated with it (precarious structure, delay on admission, lack of privacy, inadequate triage of cases, lack of professionalization); these latter aspects may be potentially modified and should be reconsidered.

The purpose of this study was to know the concordance of diagnosis between emergency rooms amd hospitalization wards and to analyze the mistake index, the epidemiological characteristics and the main reasons for the mistakes.We analyzed hospitalized patients and used a three-level concordance: exact diagnosis (A), syndromical concordance (B) and mistake (C). We compared age, sex, time and days of hospitalization between the groups A+B and C. We also analyzed the causes of mistakes in group C.We found 88.1% of patients in level A, 7.3% in level B and 4.6% in level C. There were no significant differences in the variables analyzed. Main mistakes were a deficient clinical evaluation (50%) and X-ray interpretation (28.6%).Concordance of diagnoses was the rule, with less than 5% mistakes. There is no clinical or epidemiological pattern for the mistake. The most frequent cause for it was a deficient clinical evaluation.

To know the frequency, indications and diagnosis efficiency of lumbar puncture (LP) in the Emergency Department (ED) when suspecting a central nervous system (CNS) infection.We analyzed all the LP performed over a 2-year period in the ED. We compared the clinical characteristics of patients with and without CNS infection. We also reviewed all the cases of CNS infection diagnosed in the hospital in the same period.A LP was performed in 0.4% of emergencies. In 76% of cases, it was performed because of CNS infection suspicion, which was confirmed in 30% of cases. Fever, headache, nuchal rigidity and chronical otitis were all clinical variables associated with CNS infection. An 80% of CNS infections that were not diagnosed in the ED corresponded to HIV-infected patients.Lumbar puncture is frequently performed in the ED, mostly for suspicion of CNS infection, which is eventually confirmed in one third of cases. CNS infection cases which have not been suspected in the ED usually correspond to a subacute meningitis in a HIV-infected patient.

The aim of this study was to prospectively analyze the bacterial etiology of community-acquired pneumonia in adults in Spain. From May 1994 to February 1996, 392 episodes of CAP diagnosed in the emergency department of a 600-bed university hospital were studied. An etiological diagnosis based on noninvasive microbiological investigations was achieved in 228 cases (58%); 173 of these diagnoses were definitive and 55 probable. Streptococcus pneumoniae, which caused 23.9% of the episodes, was the predominant pathogen observed, followed by Chlamydia pneumoniae (13.5%) and Legionella pneumophila (12.5%). Other less frequent pathogens found were Haemophilus influenzae (2.3%), Pseudomonas aeruginosa (1.5%), Mycoplasma pneumoniae (1.3%), Coxiella burnetii (1%), Moraxella catarrhalis (2 cases), Nocardia spp. (2 cases), and Staphylococcus aureus (2 cases). Streptococcus pneumoniae was significantly more frequent in patients with underlying disease and/or age > or =60 years (28% vs. 13%, P = 0.002), while Legionella pneumophila was more frequent in patients below 60 years of age and without underlying disease (20% vs. 9%, P = 0.006). Likewise, Streptococcus pneumoniae and Legionella pneumophila were the most frequent etiologies in patients requiring admission to the intensive care unit, occurring in 29% and 26.3% of the patients, respectively. In addition to Streptococcus pneumoniae, other microorganisms such as Chlamydia pneumoniae and Legionella spp. should be seriously considered in adults with community-acquired pneumonia when initiating empiric treatment or ordering rapid diagnostic tests.

Cirrhotic patients with hepatocellular carcinoma (HCC) frequently develop hepatic encephalopathy. Metabolic etiology of encephalopathy is less often considered in these patients. Although paraneoplastic hypercalcemia may be associated with several malignant tumors, it has also been described in HCC [1-4], and may cause neurologic disturbances. We present a case of hypercalcemic encephalopathy in a patient with hepatic cirrhosis and underlying HCC in whom first diagnostic was hepatic encephalopathy.

Fundamento Valorar la sospecha diagnosticade tromboembolia pulmonar (TEP) en elarea de urgencias. Pacientes Y Metodos Se analizan los casosde dos anos, y se compara el grupo A (sospechade TEP) con el grupo B (sin sospechade TEP). Resultados De 57 casos, no se sospechoTEP en 14 (25%). Hubo diferencias significativasen los signos de trombosis venosaprofunda (mayor frecuencia en el grupo A),insuficiencia cardiaca y derrame pleural(mayor frecuencia en el grupo B). Los diagnosticosalternativos fueron insuficienciacardiaca y neumonia. Conclusiones Los pacientes con TEP nosospechada no presentan un perfil clinicodiferencial. La TEP se confunde con insuficienciacardiaca y neumonia.

Fundamento Valorar la frecuencia y caracteristicasde las urgencias internas. Pacientes y metodos Se recogen los avisosdiarios al equipo de guardia durante unmes, analizando las caracteristicas clinicasy epidemiologicas. Resultados Se documentaron 341 avisos,con una media diaria superior en dias festivos.Se trata de problemas fundamentalmenteclinicos (78%), variables segun elservicio. Se realizaron exploraciones complementariasal 44% de los pacientes, y seindicaron modificaciones terapeuticas en el77%. Conclusiones Las urgencias internas suponenun apartado importante de la laborasistencial de los equipos de guardia, yplantean importantes valoraciones diagnosticasy terapeuticas.