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Objetivo: Analizar el impacto de la gestión clínica en los indicadores básicos de calidad en un servicio de cirugía vascular durante un período de 10 años. Métodos: Análisis retrospectivo de los indicadores asistenciales en el período 1990-2001 y la influencia que han tenido una guía de manejo clínico y la elaboración de unos estándares de calidad. Resultados: Los indicadores de calidad analizados mejoran al comparar ambos períodos. El nivel de seguridad asistencial medicoquirúrgico no se afectó por la aplicación de algoritmos de manejo y de guías de cuidados clínicos. Conclusiones: La gestión clínica basada en el binomio coste-calidad puede asegurar la eficiencia de un servicio y optimizar los recursos sin menoscabo de la calidad de los procedimientos asistenciales. Es posible definir el estándar de calidad por grupo de procedimientos, en función de la utilización de recursos hospitalarios y de las tasas de morbimortalidad.

The prognosis of patients with rheumatoid arthritis (RA) has improved substantially in the last two decades due to the appearance of biological therapies, but above all, due to the improvement in the strategy and management of the disease. Our goal in RA should be to achieve remission, or in its absence, the lowest inflammatory activity. Achieving remission will prevent from structural and functional damage highly associated with RA itself. Clinical remission is defined as the absence of significant signs and symptoms of inflammatory disease activity, as well as the abrogation of any signs of systemic inflammation. Currently, there are some controversies about remission. Which is the real remission? Which remission criteria should be used and when? Does clinical remission mean ultrasound remission? In the present review, we try to answer and put some light into it, focusing on clinical and ultrasound deep remission., (© 2020 The Mediterranean Journal of Rheumatology (MJR).)

Objectives: The aim of this study was to analyze the impact of clinical management on quality indicators in a vascular surgery unit over a 10-year period., Methods: We performed a retrospective analysis of quality indicators from 1990 to 2001 and of the influence of a clinical practice protocol and standards of quality on these indicators., Results: Comparison of both periods revealed improvement in all the quality indicators. The safety of surgical procedures was unaffected by the application of management protocols and clinical pathways., Conclusions: Clinical management based on the cost-quality binomial can ensure the efficiency of a hospital unit without adversely affecting quality of care. Quality standards based on hospital resource use, morbidity and mortality can be defined for groups of procedures.

Background: To know the usefulness of plethysmography and digital pressure indexes (DPI) to assess the vasospasm and the response to medical treatment in patients with Raynaud's phenomenon., Patients and Methods: During a four-month period, we carried out a prospective clinical trial, with a control group (15 subjects) and other of patients with Raynaud's phenomenon (40 patients). We calculated the digital pressures, plethysmography and the DPI, in basal status and after provocation with cold water. The Raynaud's group was divided randomly in two homogeneous subgroups of 20 subjects. One of the groups underwent treatment with calcium antagonists and the other group with placebo. These determinations were repeated at the middle and at the end of the treatment., Results: The basal DPI and after provocation test were lower in the Raynaud's group (0.61 [SD 0.26] and 0.25 [SD 0.26]), than in the control group (0.93 [SD 0.06] and 0.88 [SD 0.07]), with a statistical significance (p < 0.001 and p < 0.0001). After the treatment, in the subgroup treated with calcium antagonists, the DPI were increased in a statistically significative way respect to those in the placebo subgroup (p < 0.0001). Sensitivity and specificity of the DPI associated to the provocation test were of 97 and 93%, respectively. The plethysmographic wave did not suffer significant variations; sensibility and specificity were 48 and 100%., Conclusions: In the Raynaud's phenomenon the DPI associated to the provocation test have a high sensitivity and specificity, and allows determination of the degree of vasospasm and the response to treatment.

Vascular complications are rare in cases of simple anterior dislocation of the shoulder but the axillary artery or its branches may be damaged. Very few cases are found in the literature reporting false aneurysms of axillary artery secondary to blunt trauma to the shoulder. A case of pseudoaneurysm of the axillary artery in a 75-year-old woman is reported. Diagnosis was suspected because large pectoral haematoma with haemodynamic instability appeared a few hours later after manual reduction of the dislocation. The pseudoaneurysm was confirmed with selective angiography of the axillary artery. Arteriography should be performed whenever vascular injury is suspected. Delayed recognition of these lesions may lead to permanent neurologic deficits despite adequate vascular repair of the axillary artery. A coordinated vascular and orthopaedic approach and prompt surgical treatment may assure full upper limb function. Although endovascular treatment of these lesions could seem attractive, we prefer to use open surgical techniques because they allow us to treat frequent concomitant injuries and perform decompression of the axillar fossa because of the large haematoma.

Solitary internal iliac artery aneurysms are very rare. Their localisation deep in the pelvis makes diagnosis difficult. Therefore they are not detected until they reach a significant size and produce symptoms. These symptoms are due to compression on the adjacent structures or their rupture. Duplex scan, computerized tomography, and arteriography are the most useful diagnostic procedures. The correct surgical therapy consists of the ligature of the internal iliac artery and endoaneurysmorraphy with obliteration of the tributary branches. We report herein two cases of aneurysms of the internal iliac artery that made their clinical debut with signs of rupture.

The exact prevalence of visceral arteries aneurysms is not well documented and its is mainly known from necropsies. Inferior mesenteric artery aneurysms are the rarest of visceral aneurysms. The authors report a case of an aneurysm of the inferior mesenteric artery in a 52-year-old man with obstructive disease of superior mesenteric artery and celiac axis. The diagnosis was made by angiography. The aneurysm was resected with superior and inferior mesenteric arteries revascularization. Surgical approach is needed in these aneurysms and when they are associated with obstructive disease of other intestinal artery, revascularization is mandatory.

Acute ischemia due to arterial embolism occurred in the right leg of a male drug abuser who had developed fungal endocarditis as a result of Candida parapsilosis. Transesophageal echocardiography aided in the diagnosis. The patient was successfully treated with fibrinolysis and surgery. The clinical features and management of this serious condition have been reviewed in the literature.

Intestinal artery aneurysms are usually asymptomatic; however when rupture occurs, mortality rates of up to 75% have been reported. Celiac artery aneurysms are quite infrequent, only about 4% of all visceral aneurysms; their association with Aortic Aneurysms is found in 18% of cases; their association with popliteal aneurysms has not been documented so far. A case of an adult male with celiac artery aneurysm associated with Aortic and Popliteal Aneurysms is reported. The patient was operated. In a first procedure the celiac and aortic aneurysms were resected, an aortic graft was placed, and hepatic artery reimplantation was performed; in a second procedure the popliteal artery was resected and a vascular reconstruction performed. The postoperative course was uneventful, and the patient remains asymptomatic two years later. Diagnosis was based on a CT scan with selective visceral angiography. Elective surgical intervention must be performed when intestinal artery aneurysms are discovered.