Reducing errors in the management of hyperbilirubinaemia: validating a software application

OBJECTIVE

To verify the usefulness and reliability of a software tool we developed to help to apply the American Academy of Pediatrics (AAP) Guidelines 2004 on hyperbilirubinaemia according to the infant's age in hours and their clinical risk factors.

DESIGN

Randomised, cross-over, controlled trial with 20 simulated clinical cases comparing the "manual" application of the guidelines with our software application.

PARTICIPANTS

Fifteen doctors (eight final-year residents and seven consultants) from two hospitals in Spain.

MAIN OUTCOME MEASURES

Major errors (defined a priori as any deviation from the AAP guidelines that involve a risk of morbidity or mortality for the patient), minor errors (those that cause discomfort and/or, in extremely rare cases, morbidity) and time spent.

RESULTS

Fifteen doctors each managed 20 simulated cases, half by using the guidelines alone and half using the software tool. Without the software application, 42 "minor" errors were made. With it, only 25 errors were made. "Major" errors also decreased from 10 to 2 with the software. As a group, the residents benefited most; they made an average of 1.8 errors fewer per 10 cases. Use of the software reduced the time taken by the residents to resolve the cases, although the mean reduction in time was not significant for the group of consultants.

CONCLUSIONS

The use of simulated clinical cases revealed many errors in the routine management of hyperbilirubinaemia. The software helped clinicians make fewer errors and saved time for residents, but not consultants.

[Guidelines of the Spanish Society of Cardiology for clinical practice in exercise testing]

Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All the-se issues justify the need for a multidisciplinary consensus document in Spain. This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.

Lipoprotein(a) and the significance of the association between platelet glycoprotein IIIa polymorphisms and the risk of premature myocardial infarction

Platelet glycoprotein IIb/IIIa may be involved in the pathogenesis of myocardial infarction as the key element in platelet aggregation and as the binding site of lipoprotein(a) to platelets, inhibiting plasminogen binding and activation. Recently, a strong association between the P1A2 polymorphism of the glycoprotein IIIa gene and acute coronary thrombosis has been reported. although this has not been confirmed. In an associated study, we determined plasma lipoprotein levels, the apo E genotype and the P1A genotype in 250 males under 55 years with myocardial infarction and they were compared with 250 age- and sex-matched controls. Patients showed an over-representation of the epsilon3/4 genotype with respect to the control group. We found that there were no differences in the allelic frequency of P1A2 between case patients and age-matched controls (chi2 = 0.05, P = 0.92) and that subjects bearing the P1A2 allele showed higher plasma lipoprotein(a) concentration than p1A1/P1A1 individuals. Therefore, in this population there is no association between carriage of p1A2 allele and increased risk of myocardial infarction but the carriage of P1A2 is associated with higher plasma Lp(a) concentration.

[Acute myocardial infarct in a young woman addicted to cocaine]

A 28-year-old female, addict to cocaine and with acute myocardial infraction is reported. The patient was obese and smoked 17 cigarette packs per year. She had been consuming about 250 mg of cocaine daily for the last months until 2 weeks before admission. Coronary angiography showed a 100% stenosis of the left anterior descending artery. Although the vasospastic effect of cocaine on the pathogenesis of coronary ischemia in addicts is well known, most patients reported in the literature show coronary artery stenosis. This may lead to hypothesize about a likely atherogenic role of cocaine.