Pulmonary rehabilitation protocols in urgent lung transplantation patients / 世界急诊医学杂志（英文）

@#BACKGROUND: Prolonged invasive respiratory support and extracorporeal membrane oxygenation (ECMO) in patients requiring urgent lung transplantation (ULTx) present significant challenges to clinical practice due to severe underlying diseases and complex conditions. The aim of the study was to report the clinical outcomes of patients who received ULTx and followed the perioperative rehabilitation protocol implemented in a lung transplant center. METHODS: A retrospective analysis was conducted in ULTx patients who required preoperative invasive mechanical ventilation (IMV) and ECMO between January 2018 and January 2023. Data were retrieved from electronic medical records at our lung transplant center. RESULTS: Fourteen patients (mean age 57.43±10.97 years; 12 males, 2 females) underwent ULTx with bridging ECMO and IMV. The mean body mass index was 23.94±3.33 kg/m², and the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 21.50±3.96. The Nutritional Risk Screening 2002 (NRS 2002) scores were ≥3. ULTx was performed after an 8.5-day waiting period (interquartile interval [IQR] 5.0-26.5 d). Following the surgeries, the average lengths of ECMO and IMV were 1.0 (IQR 1.0-2.0) d and 5.0 (IQR 3.0-7.3) d, respectively. The total length of hospital stay was 60.1±30.8 d, with an average intensive care unit stay of 38.3±22.9 d and post-operative hospitalization stay of 45.8±26.1 d. Two patients died within 30 d after ULTx, with a 30-day survival rate of 85.71%. CONCLUSION: Patients receiving ULTx showed an acceptable short-term survival rate, validating the practicality and safety of the treatment protocols implemented in our center.

Hemorragia digestiva baja: factores de riesgo de gravedad, necesidad de cirugía de urgencia y mortalidad hospitalaria / Lower gastrointestinal bleeding: risk factors of severity, need for emergency surgery and in-hospital Mortality

RESUMEN Antecedentes: Últimamente creció el interés en poder determinar, en etapas tempranas de las hemorragias digestivas bajas (HDB), aquellos factores de riesgo relacionados con la posibilidad de presentar resultados evolutivos adversos. Objectivo: Determinar los factores de riesgo asociados a sangrados graves, cirugía de urgencia y mortalidad hospitalaria. Material y métodos: Realizamos un estudio observacional y retrospectivo sobre 1.850 pacientes, atendidos en forma consecutiva entre enero de 1999 y diciembre de 2018 por HDB. Para evaluar el riesgo de gravedad analizamos trece variables en las primeras cuatro horas desde la admisión. Para determinar los factores relacionados con la cirugía de urgencia, agregamos la enfermedad diverticular y, para evaluar mortalidad, la cirugía de urgencia y el puntaje (score) preoperatorio de la Sociedad Americana de Anestesiología (ASA). Resultados: De los 1.850 casos, 194 fueron graves y 1656 leves/moderados. Resultaron estadísticamente significativos como factores de mayor gravedad: > 70 años, FC > 120 lat/min., TA < 90 mm Hg, oliguria, hematoquecia masiva, hematocrito < 30%, hemoglobina < 7 g/% y necesidad transfusional. Resultaron predictores significativos de cirugía de urgencia: > 70 años, anti-coagulación, hipotensión arterial, taquicardia, hemoglobina < 7 g/%, oliguria, transfusiones y hematoquecia masiva. Se construyó una fórmula pronóstica de requerimiento de cirugía (sensibilidad 94%, especificidad 74%, valor predictivo positivo 91% y valor predictivo negativo 81%). AUC: 0,89%. Fueron significativos para mortalidad: > 70 años, anticoagulados, hematoquecia masiva, transfusiones y cirugía urgente. De los dieciséis pacientes operados y fallecidos de la serie, quince presentaban un ASA ≥ IV. Conclusiones: Las variables utilizadas resultaron simples, fiables y estadísticamente significativas para predecir gravedad, cirugía de urgencia y mortalidad.

ABSTRACT Background: Background: There has been a growing interest in determining those risk factors associated with adverse outcomes in early stages of lower gastrointestinal bleeding (LGIB). Objective: The aim of our study was to analyze the risk factors associated with severe bleeding, emergency surgery and in-hospital mortality. Material and methods: We conducted an observational and retrospective study on 1850 patients consecutive managed between January 1999 and December 2018 for LGIB. We analyzed thirteen variables within the first four hours of hospitalization to evaluate risk severity. Diverticular disease was considered to determine factors associated with emergency surgery, and the preoperative American Society of Anesthesiologists (ASA) score was used to assess mortality and emergency surgery. Results: Out of 1850 cases, 194 were severe and 1656 were mild/moderate, Patients > 70 years, with HR > 120 beats/min, BP < 90 mm Hg, oliguria, massive hematochezia, hematocrit < 30%, hemoglobin < 7 g% and need for transfusions presented statistically significant associations with severe bleeding. Age > 70 years, anticoagulation, hypotension, tachycardia, hemoglobin < 7 g%, oliguria, need for transfusion and massive hematochezia were significant predictors of emergency surgery. A prognostic formula was constructed to predict the need for surgery (sensitivity 94%, specificity 74%, positive predictive value 91% and negative predictive value 81%). AUC-ROC: 0,89%. Age > 70 years, anticoagulation, massive hematochezia transfusions and emergency surgery were identified as predictors of mortality. Fifteen of the sixteen patients who underwent surgery and died had ASA ≥ grade 4. Conclusions: The variables analyzed are simple, reliable and statistically significant to estimate the risk of severe bleeding, need for emergency surgery and mortality.

Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries / 中华创伤杂志(英文版)

PURPOSE@#To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees' performance for emergent and urgent thoracic surgeries.@*METHODS@#With a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models. Five operation teams from basic-level hospitals (group A) and five operation teams from level III hospitals (group B) were included to be trained and tested. Testing standards for the operations were established after thorough literature review, and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Tests were carried out after the training. Pre- and post-training performances were compared. Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches.@*RESULTS@#Animal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%. After literature review, testing standards were established, and expert questionnaire results showed that the scientific score was 7.30 ± 1.49, and the feasibility score was 7.50 ± 0.89. Post-training performance was significantly higher in both group A and group B than pre-training performance. Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury.@*CONCLUSIONS@#Animal model-based simulation training established in the current study could improve the trainees' performance for emergent and urgent thoracic surgeries, especially of the surgical teams from basic-level hospitals.

Expert Consensus on Acute Respiratory Failure in Critically Ill Cancer Patients (2023) / 中国医学科学杂志(英文版)

Objective This consensus aims to provide evidence-based recommendations on common questions in the diagnosis and treatment of acute respiratory failure (ARF) for critically ill cancer patients.Methods We developed six clinical questions using the PICO (Population, Intervention, Comparison, and Outcome) principle in diagnosis and treatment for critical ill cancer patients with ARF. Based on literature searching and meta-analyses, recommendations were devised. The GRADE (Grading of Recommendation Assessment, Development and Evaluation) method was applied to each question to reach consensus in the expert panel. Results The panel makes strong recommendations in favor of (1) metagenomic next-generation sequencing (mNGS) tests may aid clinicians in rapid diagnosis in critically ill cancer patients suspected of pulmonary infections; (2) extracorporeal membrane oxygenation (ECMO) therapy should not be used as a routine rescue therapy for acute respiratory distress syndrome in critically ill cancer patients but may benefit highly selected patients after multi-disciplinary consultations; (3) cancer patients who have received immune checkpoint inhibitor therapy have an increased incidence of pneumonitis compared with standard chemotherapy; (4) critically ill cancer patients who are on invasive mechanical ventilation and estimated to be extubated after 14 days may benefit from early tracheotomy; and (5) high-flow nasal oxygen and noninvasive ventilation therapy can be used as a first-line oxygen strategy for critically ill cancer patients with ARFs. A weak recommendation is: (6) for critically ill cancer patients with ARF caused by tumor compression, urgent chemotherapy may be considered as a rescue therapy only in patients determined to be potentially sensitive to the anticancer therapy after multidisciplinary consultations. Conclusions The recommendations based on the available evidence can guide diagnosis and treatment in critically ill cancer patients with acute respiratory failure and improve outcomes.

Emergency department use and Artificial Intelligence in Pelotas: design and baseline results / Uso serviços de serviços de urgência e emergência e Inteligência Artificial em Pelotas: protocolo e resultados iniciais

RESUMO Objetivo: To describe the initial baseline results of a population-based study, as well as a protocol in order to evaluate the performance of different machine learning algorithms with the objective of predicting the demand for urgent and emergency services in a representative sample of adults from the urban area of Pelotas, Southern Brazil. Methods: The study is entitled "Emergency department use and Artificial Intelligence in PELOTAS (RS) (EAI PELOTAS)" (https://wp.ufpel.edu.br/eaipelotas/). Between September and December 2021, a baseline was carried out with participants. A follow-up was planned to be conducted after 12 months in order to assess the use of urgent and emergency services in the last year. Afterwards, machine learning algorithms will be tested to predict the use of urgent and emergency services over one year. Results: In total, 5,722 participants answered the survey, mostly females (66.8%), with an average age of 50.3 years. The mean number of household people was 2.6. Most of the sample has white skin color and incomplete elementary school or less. Around 30% of the sample has obesity, 14% diabetes, and 39% hypertension. Conclusion: The present paper presented a protocol describing the steps that were and will be taken to produce a model capable of predicting the demand for urgent and emergency services in one year among residents of Pelotas, in Rio Grande do Sul state.

RESUMO Objetivo: Descrever os resultados iniciais da linha de base de um estudo de base populacional, bem como um protocolo para avaliar o desempenho de diferentes algoritmos de aprendizado de máquina, com o objetivo de predizer a demanda de serviços de urgência e emergência em uma amostra representativa de adultos da zona urbana de Pelotas, no Sul do Brasil. Métodos: O estudo intitula-se "Emergency department use and Artificial Intelligence in PELOTAS (RS) (EAI PELOTAS)" (https://wp.ufpel.edu.br/eaipelotas/). Entre setembro e dezembro de 2021, foi realizada uma linha de base com os participantes. Está previsto um acompanhamento após 12 meses para avaliar a utilização de serviços de urgência e emergência no último ano. Em seguida, serão testados algoritmos de machine learning para predizer a utilização de serviços de urgência e emergência no período de um ano. Resultados: No total, 5.722 participantes responderam à pesquisa, a maioria do sexo feminino (66,8%), com idade média de 50,3 anos. O número médio de pessoas no domicílio foi de 2,6. A maioria da amostra tem cor da pele branca e ensino fundamental incompleto ou menos. Cerca de 30% da amostra estava com obesidade, 14% com diabetes e 39% eram hipertensos. Conclusão: O presente trabalho apresentou um protocolo descrevendo as etapas que foram e serão tomadas para a produção de um modelo capaz de prever a demanda por serviços de urgência e emergência em um ano entre moradores de Pelotas, no estado do Rio Grande do Sul.

Diálisis peritoneal de inicio urgente, un reto para el nefrólogo

La diálisis peritoneal (DP), es una terapia costo efectiva, poco utilizada a nivel mundial. DP de inicio urgente es definido como el inicio de terapia en pacientes incidentes, inmediatamente después o antes de las dos semanas de haber sido colocado un catéter para DP crónica en pacientes con insuficiencia renal crónica con indicación de diálisis de urgencia, comparado con el inicio convencional después de dos semanas. El objetivo fue revisar la información actual sobre la DP de inicio urgente. Se realizó una búsqueda en PubMed, The Cochrane Library y SciELO. Se incluyeron 12 artículos publicados hasta el 31 de octubre de 2021. Se encontró una baja incidencia de pacientes que ingresan a DP, más aún la DP de inicio urgente. No se encontró diferencia significativa que justifique la espera para utilizar el catéter implantado, pudiendo evitar la hemodiálisis en urgencia dialítica. Un metaanálisis con 16 estudios (2953 pacientes) concluye que la DP de inicio urgente comparada con la de inicio convencional no aumentó la muerte de cualquier causa (1 ECA: RR 1,49, IC 95%: 0,87 a 2,53; 7 estudios de cohortes: RR 1,89, IC 95%: 1,07 a 3,3; 1 estudio de casos y controles: RR 0,90, IC 95%: 0,27 a 3,02). Otro metaanálisis con 6 estudios (1242 pacientes) reporta certeza muy baja en la mortalidad (RR: 1,25, IC 95%: 0,92 a 1,69; I2=0%, p=0,99), complicaciones mecánicas con mayor prevalencia de fugas (RR: 6,72, IC 95%: 2,11 a 21,32; I2=0%, p=0,60), y no hubo diferencia en complicaciones infecciosas entre los dos grupos. (RR: 1,36, IC 95%: 0,90 a 2,05, p=0,14). Se concluye que, no existe diferencia significativa entre la DP de inicio urgente y la de inicio convencional, en la sobrevida del paciente ni en la sobrevida de la técnica. La comunidad nefrológica debe considerar a la DP de inicio urgente como una opción de terapia en pacientes que requieran diálisis de urgencia.

SUMMARY Peritoneal dialysis (PD) is a cost-effective therapy, little used worldwide. Urgent start PD is defined as the start of therapy in incident patients, immediately after or before two weeks after having placed a catheter for chronic PD in patients with chronic renal failure with indication of urgency dialysis, compared with the conventional start after two weeks. The objective was to review the current information on urgent start PD. A search was performed in PubMed, The Cochrane Library and SciELO. A total of 12 articles published up to October 31, 2021, were included. A low incidence of patients admitted to PD was found, even more so in urgent start PD. No significant differences were found that justify waiting to use the implanted catheter, thus avoiding hemodialysis in dialysis urgency. A meta-analysis with 16 studies (2953 patients) concluded that urgent start PD compared with conventional start did not increase death from any cause (1 RCT: RR 1.49, CI 95%: 0.87 to 2.53; 7 cohort studies: RR 1.89, CI 95%: 1.07 to 3.3, 1 case control study: RR 0.90, CI 95%: 0.27 to 3.02). Another meta-analysis with 6 studies (1242 patients) reports very low certainty in mortality (RR: 1.25, CI 95%: 0.92 to 1.69; I2=0%, p=0.99), mechanical complications with higher prevalence of leaks (RR: 6.72, CI 95%: 2.11 to 21.32; I2=0%, p=0.60), and there was no difference in infectious complications between the two groups. (RR: 1.36, CI 95%: 0.90 to 2.05, p=0.14). It is concluded that there is no significant difference between urgent start PD and conventional start, in patient survival or in the survival of the technique. The nephrology community should consider urgent start PD as a therapy option in patients requiring urgency dialysis.

Accessibility to urgent and emergency care services in low-density territories: the case of Baixo Alentejo, Portugal / Acessibilidade à rede de serviços de urgência em territórios de baixa densidade: o caso do Baixo Alentejo, Portugal

Abstract Access to health care is a sensitive issue in low population density territories, as these areas tend to have a lower level of service provision. One dimension of access is accessibility. This paper focuses on measuring the accessibility to urgent and emergency care services in the Portuguese region of Baixo Alentejo, a territory characterized by low population density. Data for the calculation of accessibility is the road network, and the methodology considers the application of a two-level network analyst method: time-distance by own mean (car or taxi) to the urgent care services and the time distance to emergency services as a way to get assistance and to go to urgent care services. While urgent care accessibility meets the requirements stipulated in the Integrated Medical Emergency System's current legislative framework, the simulation of different scenarios of potential accessibility shows intra-regional disparities. Some territories have a low level of accessibility. Older adults, the poorly educated, and low-income population, also have the lowest levels of accessibility, which translates into dually disadvantageous situation since the potential users of emergency services are most likely to belong to this group of citizens.

Resumo Em territórios de baixa densidade populacional, o acesso aos cuidados de saúde é uma questão delicada, pois essas áreas tendem a ter um nível mais baixo de prestação de serviços. Uma dimensão do acesso é a medição da acessibilidade. Este artigo tem como propósito medir a acessibilidade aos serviços de urgência e aos meios de emergência médica na região portuguesa do Baixo Alentejo, território caracterizado por uma baixa densidade populacional. A metodologia considera o método network analyst aplicado à rede viária, em dois níveis: o cálculo da distância-tempo aos serviços de urgência usando modo próprio (carro ou táxi); e o cálculo da distância-tempo recorrendo aos meios de socorro e emergência como forma de aceder aos serviços de urgência. Embora se considere que a acessibilidade às urgências atende ao atual quadro legislativo do Sistema Integrado de Emergência Médica, a simulação de diferentes cenários no Baixo Alentejo mostra a existência de disparidades intra-regionais no que se refere à acessibilidade aos serviços de urgência. Verifica-se que é a população idosa, de baixa instrução e residente em zonas com baixa densidade populacional quem apresenta menores índices de acessibilidade, o que traduz uma situação duplamente desvantajosa, uma vez que estes são os maiores utilizadores destes serviços.

Prognostic analysis of different urgent-start dialysis methods in elderly patients with end-stage renal disease / 中华老年医学杂志

Objective:To investigate whether peritoneal dialysis can replace hemodialysis as an option for urgent-start dialysis for elderly patients with end-stage renal disease who need emergency initial dialysis.Methods:This was a retrospective cohort study, with enrolment of patients ≥65 years with end-stage renal disease who started hemodialysis or peritoneal dialysis for the first time at the nephrology department of our hospital between January 1, 2013 and June 1, 2019 and were followed up regularly.All patients started dialysis within 5 days of catheterization.According to different dialysis methods, patients were divided into the urgent-start hemodialysis(USHD)group and the urgent-start peritoneal dialysis(USPD)group, and were followed up until December 31, 2019.Short-term(30 days after the procedure)dialysis-related complications and survival were compared between the two groups.Results:A total of 89 elderly patients with end-stage renal disease receiving urgent-start dialysis were included, with 40 cases in the USPD group and 49 cases in the USHD group.There was no significant difference in the incidences of infection-related complications(0.0% vs.2.5%), non-infection-related complications(2.0% vs.2.5%), re-catheterization(0 vs.0)and bacteremia(0 vs.0)between the two groups( P> 0.05). The Kaplan-Meier survival curve showed that the median survival times of patients with USHD and with USPD were 63.0 months and 38.0 months, respectively, with no statistical significance(Log Rank, χ2=0.025, P=0.88). The Charlson comorbidity index( HR: 1.205, 95% CI: 1.026-1.415, P=0.023)and albumin level( HR: 0.949, 95% CI: 0.903-0.997, P=0.037)were independent risk factors for the survival and prognosis of elderly patients with urgent-start dialysis.Furthermore, we stratified and made an interactive analysis of the albumin level and the comorbidity index of elderly patients with urgent-start dialysis and found that there was no significant difference between the two modes of dialysis in the survival rate of elderly patients with end-stage renal disease( P>0.05). Conclusions:It is safe and effective to start dialysis within 5 days after peritoneal dialysis catheterization.For elderly patients with end-stage renal disease, peritoneal dialysis can replace hemodialysis as an option for urgent-start dialysis.

Protocolo de Teleodontología para Asistencia al Paciente en el Manejo de Urgencia Dental. Cuarentena COVID-19 (SARS-CoV-2). Categorización Remota de Urgencia Dental y Asistencia (C.R.U.D.A.) / Teledentistry Protocol for Patient Assistance in Emergency Dental Management. Quarantine COVID-19 (SARS-CoV-2). Remote Categorization of Dental Emergency and Assistance (C.R.U.D.A. for its Spanish Acronym)

RESUMEN: En el contexto de cuarentena debido a la pandemia SARS-CoV-2, la odontología ha migrado a mecanismos remotos de atención para categorizar emergencias y urgencias. Sin embargo, no hay evidencia de protocolos validados de teleodontología aplicado al triaje remoto de urgencia en la literatura. Por ello, proponemos el instrumento denominado "Categorización Remota de Urgencia Dental y Asistencia" (C.R.U.D.A), aplicado a un protocolo de teleodontología. Para la construcción del protocolo, usamos la metodología de investigación-acción, un ciclo de autoreflexión frente al problema existente que buscamos solucionar, un espiral repetitivo de ciclos de planeamiento, acción, observación sistemática y reflexión, con el que fuimos perfeccionando el instrumento de forma colaborativa y rigurosa. Los objetivos del protocolo son estandarizar, optimizar y automatizar el proceso de categorización de urgencia dental gracias a su especificidad, disminuyendo el tiempo y complejidad de su aplicación a gran escala, permitiendo descongestionar el sistema de salud, y disminuir el riesgo de exposiciones innecesarias, protegiendo de esta forma al personal clínico y pacientes. Al mismo tiempo, su nivel de legibilidad permitiríamejorar la comunicación y orientación al paciente. En definitiva, el protocolo propuesto es viable y cumple con las características para optimizar el proceso de teletriaje actual, potenciando la atención personalizada entre odontólogos y pacientes. Sin embargo, es necesario realizar estudios de aplicabilidad y validez, además de incorporar las mejoras correspondientes según los errores o defectos detectados por pacientes y cirujano dentistas.

ABSTRACT: In the context of quarantine due to the SARS-CoV-2 pandemic, dentistry has migrated to remote care mechanisms to categorize emergencies and casualties.However, there is no evidence of validated teledentistry protocols applied to remote emergency triage in the literature. Therefore, we propose an instrument called "Remote Categorization of Dental Emergency and Assistance" (C.R.U.D.A., for its Spanish acronym), applied to a teledentistry protocol. For the construction of the protocol, we used the action-research methodology, a self-reflection cycle to solve an existing problem, a constant repetition of planning, action, systematic observation, and reflection, with which we perfected the instrument in a collaborative and rigorous way. The objectives of the protocol are to standardize, optimize and automate the process of categorization of dental emergencies thanks to its specificity, decreasing the time and complexity of its application on a large scale, allowing to decongest the health system and to diminish the risk of unnecessary exposures, thus protecting clinical staff and patients. At the same time, its level of readability would allow for improved communication and patient orientation. In short, the proposed protocol is viable and meets the characteristics to optimize the current teletriage process, enhancing personalized attention between dentists and patients. However, it is necessary to carry out applicability and validity studies, in addition to incorporating the corresponding improvements according to the errors or defects detected by patients and dental surgeons.

Caracterización del adulto mayor con urgencia psiquiátrica en el Hospital Psiquiátrico "Luis Ramírez López", Guantánamo 2019 / Characterization of the elderly patient with psychiatric urgency in the Psychiatric Hospital "Luis Ramírez López", Guantanamo 2019

RESUMEN Introducción: En el Hospital Psiquiátrico "Luis Ramírez López" de la provincia de Guantánamo no se han caracterizado a los ancianos atendidos en el servicio de Urgencias. Objetivo: Caracterizar a los pacientes adultos mayores con urgencia psiquiátrica atendidos en el servicio de Urgencias del citado hospital durante el año 2019. Método: Se realizó un estudio descriptivo, retrospectivo y transversal. En el total de pacientes atendidos (N=1 427) se estudiaron las siguientes variables: sexo, edad, área de procedencia, diagnóstico y conducta a seguir. Resultados: El 64,4 % de los pacientes fue mujeres y el 35,6 % fue hombres, los que tenían edades entre 60 y 69 años (57,9 %) y procedían del área sur del municipio de Guantánamo (30,3 %). Fue más común el diagnóstico de trastornos afectivos (32,7 %) y que se les ofreciera tratamiento ambulatorio (81,4 %). Conclusiones: Es elevada la demanda de atención psiquiátrica de urgencia por parte de paciente adultos mayores, sobre todo, porque presentan trastornos afectivos que requieren atención ambulatoria.

ABSTRACT Introduction: The elderly assisted in the urgency service in the Psychiatric Hospital Luis Ramirez Lopez has not been characterized. Objective: To characterize the elderly patients with a psychiatric urgency assisted in the urgency service of the already mentioned institution during the year 2019. Method: A descriptive, retrospective, cross-sectional study was carried out. The following variables were studied in the total of assisted patients (N=1427): sex, age, area of origin, diagnosis and steps to follow with the patient. Results: 64.4% of the patients were women and the 35.6% men, with an average age between 60 and 69 years (57.9%) and who came from the south area of the municipality of Guantánamo (30.3%). The most common diagnoses were affective dysfunctions (32.7%), mostly with ambulatory treatment (81.4%). Conclusions: It is considerably high the demand on psychiatric attention in urgency service for elderly patients, mainly because of affective dysfunctions that require ambulatory attention.

Role of emergency coronary artery bypass grafting in the era of percutaneous interventions

Background: In acute coronary syndrome, prompt restoration of myocardial blood flow is essential to optimize myocardial salvage and decrease mortality. Coronary artery reperfusion, if performed in a timely manner improves clinical outcomes compared to no reperfusion. Fibrinolysis and percutaneous interventions can restore blood flow in an acutely occluded coronary artery in most of the patients; but in a few subset of patients coronary artery bypass grafting (CABG) is needed to effectively restore blood flow.Methods: A retrospective study was conducted among all CABGs performed during March 2016 - February 2018. During this period, 366 CABGs were performed and 57 patients underwent emergency CABG as per the inclusion criterias. Pre-operative, intra-operative and post-operative data was analysed of these patients. Patients were divided into four groups based on the time of surgery from the time of onset of myocardial infarction.  Results: 57 patients underwent emergency CABG with males constituting 94.7% of the study population. 78.9% of them had an ejection fraction less than 35%. 52% presented with low cardiac output status, 10% needed intra-aortic balloon pump support and 15% required mechanical ventilation prior to surgery. All patients received an average of 2.8 grafts. Mortality was 5%Conclusions: Immediate surgical revascularisation of patients presenting with acute MI is feasible. Emergency CABG not only treats the culprit lesion but also achieves complete revascularization and offers a clear advantage for patients. The optimal timing of CABG for patients with acute MI remains difficult to establish.

Atendimento às urgências oftalmológicas em unidade de pronto atendimento / Assistance to ophthalmic urgencies in emergency care unit

Objetivo: Descrever os atendimentos oftalmológicos realizados em uma unidade geral de pronto atendimento. Métodos: Estudo prospectivo, observacional e descritivo cuja coleta de dados foi realizada em prontuários de pacientes atendidos na unidade por queixas oftalmológicas no período entre julho e novembro de 2018. Resultados: Foram revisados 445 prontuários de pacientes oftalmológicos, representando 2,18% do número total de pacientes atendidos no período. Foram encontrados 182 (40,89%) pacientes com diagnóstico de conjuntivite, 139 (31,23%) de trauma ocular e 78 (17,52%) com outros diagnósticos. Dentre os pacientes com trauma ocular, 115 (82,73%) eram do sexo masculino e 42 resultaram de acidente de trabalho. Conclusões: Conclui-se que a maioria dos pacientes oftalmológicos foi atendida com diagnóstico de conjuntivite ou trauma ocular e parte desses não faziam uso de EPI no momento da ocorrência. Os resultados permitem inferir que os médicos plantonistas precisam ter noções sobre as doenças oftalmológicas prevalentes na unidade de pronto atendimento e que desponta a necessidade de se promover campanhas para a prevenção de acidentes de trabalho junto às empresas da região, acompanhadas de fiscalização, para reduzir o acometimento de pacientes com trauma ocular resultante da não observância das normas de proteção.

Objective: To describe the ophthalmologic services performed in a general emergency care unit. Methods: Prospective, observational and descriptive study whose data collection was performed on medical records of patients seen at the unit for eye complaints in the period between July and November 2018. Results: 445 medical records of ophthalmological patients were reviewed, representing 2,18% of the number total number of patients seen in the period. 182 (40.89%) patients were diagnosed with conjunctivitis, 139 (31.23%) with ocular trauma and 78 (17.52%) with other diagnoses. Among the patients with ocular trauma, 115 (82.73%) were male and 42 resulted from an occupational accident. Conclusions: Most ophthalmologic patients were treated with a diagnosis of conjunctivitis or ocular trauma and part of them did not use PPE at the moment of the accident. The results allow us to infer that physicians on duty need to have knowledge about the ophthalmological diseases prevalent in the emergency care unit and that there is a need to promote campaigns for the prevention of work accidents with companies in the region, accompanied by inspection, reducing the involvement of patients with eye trauma who were not obeying the rules of protection.

Epidemiological profile of non-urgent patient visits to emergency department in a tertiary care hospital in South India

Background: Non-urgent visits to emergency department (ED) form a significant proportion of ED visits. The reasons vary from minor injuries, fever of short duration, parental anxiety, and even serious conditions like myocardial infarctions presenting atypically. Non-urgent visits stress the ED services while prolonged waiting affects the patients. The aim was to study the profile of non-urgent visits to emergency department of a tertiary care hospital in South India.Methods: Prospective and descriptive study of patients aged 15 years and above categorized as non-urgent after triage was conducted. Data such as age, gender, reason for visit, time of presentation during the day, duration of ED stay and need for referral were recorded. Quantitative variables were presented as Mean±SD and frequency with percentage for qualitative variables.Results: Non-urgent visits contributed to 47.1% of total ED visits. Reasons for non-urgent visits were fever (15.4%), vomiting (13.9%), breathlessness (7.6%), minor trauma (7.3%), giddiness (7.0%) and dysuria (5.5%). 80.8% of all non- urgent visits were seen by ED doctor within two hours of being triaged. Most patients were treated for their immediate symptoms and 64.8% needed follow-up out-patient appointments. Admission rate was 1.2%. Majority of non-urgent visits (55.7%) were daytime visits and 13% were after-hours.Conclusions: Non-urgent visits contribute to about half of all ED visits and can stress ED. A local triage guideline is necessary to run these services in ED. Extended general practice or family physician run urgent care can relieve the stress on ED while rendering to patients accessible and affordable care.

Improvement of Urgent Tests Laboratory Turnaround Time Through Laboratory Lean Management

@#Introduction: Laboratory turnaround time (LTAT) is considered a reliable indicator of the quality and efficiency of a laboratory’s service. LTAT achievement, particularly of urgent tests, remains unsatisfactory and challenging in many clinical laboratories especially in tertiary health care centres with high workload and restricted resources. The unresolved issue of unsatisfactory urgent renal profile (RP) LTAT below the standard performance goal prompted our interest to improve laboratory’s handling of urgent test request. We thus implemented the Lean principle in the management of urgent test requests using urgent RP as the test model. Methods: The implementation of laboratory Lean involved 4 steps process; (1) Development of burning platform for change (2) Identification of waste (3) Planning and implementation of control measures (4) Measuring, monitoring, and sustaining the improvement. Urgent RP LTAT and the percentage of the request met the time requirement determined based on the data extracted from laboratory information system (LIS) before and after the implementation of Lean was compared to assess the effectiveness. Results: Urgent RP LTAT after the implementation of Lean was reduced i.e 35 min (before) vs 31 min (after), with the percentage of LTAT met the time requirement was significantly increased above the set target i.e 82.8% (before) to 93.5% (after) with P-value = 0.001. Conclusion: Implementation of innovation using Lean management has significantly improved urgent RP LTAT achievement, thus optimised urgent test management in our Chemical Pathology laboratory. Lean is a strongly recommended strategy to improve urgent test LTAT especially in laboratories with restricted resources.

Análise da Percepção de Acadêmicos sobre o Ensino de Urgência e Emergência em Curso Médico / Analysis of the Perception of Academics about Emergency and Emergency Medical Education

Resumo: Introdução: O atendimento em urgência e emergência (UE) envolve situações de risco que exigem intervenção imediata para aumentar as chances de sobrevivência do paciente. O ensino dessa disciplina durante a graduação de Medicina não tem sido efetivo, e os alunos apresentam deficiência no atendimento, tornando-se importante realizar avaliação para conhecer a realidade sobre esse processo formativo. O objetivo deste estudo foi avaliar o conhecimento e a satisfação pessoal dos acadêmicos de Medicina que se encontram no internato quanto à disciplina de Urgência e Emergência, em faculdade privada do norte de Minas Gerais. Método: Trata-se de um estudo transversal, quantitativo e descritivo, com aplicação de 185 questionários que abordaram dados demográficos, conhecimento da política de atenção à UE aplicada ao Samu, conhecimento da epidemiologia dos atendimentos pré-hospitalares do Samu, avaliação e conduta durante o atendimento, e percepção do ensino de UE. A população foi constituída por estudantes de Medicina, do oitavo ao 12º período, divididos em dois grupos em relação ao estágio em UE. Realizou-se análise estatística por meio do teste qui-quadrado de Pearson ou exato de Fisher com significância p < 0,05. Resultados: A população foi predominantemente do sexo feminino. Quanto à opção de trabalho, 123 (66,5%) dos estudantes optaram por consultório médico, 35,1% escolheram os serviços de UE, e 95 (51,4%) citaram a saúde da família. Quanto aos profissionais que compõem a ambulância básica ou avançada, 40,5% e 54,1% acertaram a composição da básica e avançada, respectivamente, sendo estatisticamente significante com p-valor 0,001 e 0,002. Dos participantes do estudo, 15,7% marcaram corretamente todas as causas de atendimento pelo Samu, e 36,2% acertaram a natureza clínica como a maior demanda de atendimento. Não houve diferenças estatísticas quanto à percepção da importância do conhecimento do médico generalista sobre UE. Quanto à percepção dos acadêmicos em relação à própria formação, foi identificada diferença estatística nas questões relacionadas às temáticas triagem - Protocolo de Manchester, monitorização, suporte básico e avançado de vida, e emergências pediátricas. Conclusões: O ensino de UE, na percepção dos alunos, mostra-se efetivo nessa avaliação, mas com lacunas em urgências pediátricas e toxicológicas. Os alunos formam-se inseguros quanto ao atendimento nessa área. Há a necessidade de discutir mais essa temática por causa da relevância dela para a prática profissional.

Abstract: Introduction: Urgency and emergency service involves risk situations that require immediate intervention to increase the patient's chances of survival. The teaching of this discipline during undergraduate medical school has not been effective and the students show deficient training; thus, carrying out an evaluation aiming to know the reality about this formative process becomes important. Objectives: to evaluate the knowledge and personal satisfaction of the undergraduate medical students attending internship regarding the discipline of Urgency and Emergency, in private medical schools in the North of Minas Gerais. Method: transversal, quantitative, descriptive study, which applied 185 questionnaires addressing demographic data; knowledge of the Urgency and Emergency care policy applied to SAMU; knowledge of the epidemiology of pre-hospital care at SAMU, assessment and conduct during care; and perception of UE education. The population consisted of medical students, from the 8th to the 12th periods of medical school, divided into two groups in relation to the internship in UE. The statistical analysis was performed using Pearson's Chi-square test or Fisher's exact test, with significance set at p <0.05. Results: The population was predominantly female. As for the job option, 123 (66.5%) chose working at a doctor's office, 35.1% chose UE services, and 95 (51.4%) cited family health. As for the professionals who work at the basic or advanced ambulance, 40.5% and 54.1% agreed on the composition of the basic and advanced ambulances, respectively. Being statistically significant with a p-value of 0.001 and 0.002. 15.7% correctly answered all causes of care provided by SAMU, and 36.2% correctly answered the clinical nature as the highest demand for care. There were no statistical differences regarding the perception of the importance of the general practitioner's knowledge of urgency and emergency. Regarding the perception of students in relation to their training, a statistical difference was identified in questions related to the topics Screening - Manchester protocol, Monitoring, Basic and advanced life support, Pediatric emergencies. Conclusions: the urgency and emergency teaching, according to the students' perception, is effective in this evaluation, but has gaps in pediatric and toxicological emergencies. Students are unsure of how to work in this area. It is necessary to further discuss this topic, due to its relevance to professional practice.

El fondo de ojo en la urgencia médica no oftalmológica / The fundus of the eye in the non-ophthalmologic medical emergency

RESUMEN El fondo de ojo es considerado por muchas especialidades médicas un proceder complementario. ¿Existe una correcta indicación del fondo de ojo de urgencia? Objetivo: Identificar los principales motivos de indicación del fondo de ojo urgente y su pertinencia. Métodos: Se realizó un estudio descriptivo transversal en el periodo comprendido desde el 29 de mayo hasta el 1ro. de diciembre del año 2018, en una muestra de 59 pacientes de un universo de 67 casos con indicación de fondo de ojo urgentes, a realizarse en la consulta del Cuerpo de Guardia de Oftalmología en la Unidad de Cuidados Intensivos Especiales y en salas intrahospitalarias del Hospital General Docente Provincial "Antonio Luaces Iraola", de la provincia de Ciego de Ávila, Cuba. Resultados: El 28,8 por ciento de los fondos de ojos fueron ordenados por Medicina Interna, seguido por Pediatría y Ginecobstetricia con 20,3 por ciento cada uno. El antecedente patológico personal ocular más frecuente fue la ametropía y el familar el glaucoma. El antecedente patológico personal sistémico más frecuente fue la hipertensión arterial. Las razones que motivaron su indicación urgente, en orden de frecuencia, fueron: el síndrome de hipertensión arterial en gestantes, el síndrome de cefalalgia, el traumatismo craneoencefálico en puérperas, el síndrome febril y el síndrome vertiginoso. Solo en 2 pacientes se visualizaron signos de sospecha de glaucoma, sin otras alteraciones a nivel de la papila óptica, y retina del polo posterior en los casos restantes. Conclusiones: Todos los fondos de ojos realizados fueron negativos para papiledema, signo que presumiblemente debe descartarse, en dependencia del motivo y la especialidad que lo indique con urgencia(AU)

ABSTRACT The fundus of the eye is considered, by many medical specialties, a complementary procedure. Is there a correct indication of the fundus of the eye as an emergency? Objective: To identify the main reasons for the indication of the fundus of the eye as an emergency and its relevance. Methods: A descriptive and cross-sectional study was carried out in the period from May 29 to December 1, 2018, with a sample of 59 patients from a study group of 67 cases with indication of urgent fundus of the eye to be carried out in the service of the Ophthalmology Emergency Room belonging to the Special Intensive Care Unit and in hospital wards of Professor Antonio Luaces Iraola General Hospital of Ciego de Ávila Province, Cuba. Results: 28.8 percent of the fundus of the eye were ordered by internal medicine, followed by pediatrics and gynecobstetrics, each accounting for 20.3 percent. The most frequent personal pathological ocular history was ametropia and the glaucoma family. The most frequent systemic personal pathological history was arterial hypertension. The reasons that motivated its urgent indication, in order of frequency, were the syndrome of hypertension in pregnant women, the headache syndrome, the traumatic brain injury in postpartum women, the febrile syndrome, and the vertiginous syndrome. Only two patients showed signs of suspected glaucoma, without other alterations at the level of the optic papilla, and retinal posterior pole in the remaining cases. Conclusions: All the fundus of eyes carried out were negative for papiledema, a sign that presumably must be discarded, depending on the reason and the specialty that indicates it with urgency(AU)

Conhecimento e atuação da equipe de enfermagem de um setor de urgência no evento parada cardiorrespiratória / The knowledge and acting of a nursing team from a sector of cardiorespiratory arrest urgent care / Conocimiento y actuación del equipo de enfermería de un sector de urgencia en el evento parada cardiorrespiratoria

Objective: The study's purpose has been to describe the knowledge and performance of an urgency nursing team of the University Hospital from the Universidade Federal do Vale do São Francisco in Petrolina city, Pernambuco State, with regards to the cardio respiratory arrest event. Methods: It is a descriptive and cross-sectional study with a quantitative approach, which was carried out through a non-probabilistic sample of 101 nursing professionals who answered a questionnaire. Data were analyzed by observing the frequencies of each isolated response and the crossing of variables. Results: Twenty-three nurses and 78 nurse technicians were interviewed. Regarding the detection of a cardio respiratory arrest, immediate conduct, and the actions of both the basic life support and advanced life support, most professionals answered in a partially correct way. Conclusion: The low percentage of totally correct answers evidences the need to update the entire nursing team, maintaining the uniformity of the professional performance, thus improving the care provided to the patient showing serious health condition

Objetivo: Descrever o conhecimento e atuação da equipe de enfermagem da urgência do Hospital Universitário da Universidade Federal do Vale do São Francisco de Petrolina/PE, perante o evento PCR. Métodos: Estudo quantitativo, descritivo e transversal por uma amostragem não probabilística de 101 profissionais de enfermagem que responderam a um questionário. Os dados foram analisados por meio da observação das frequências de cada resposta isolada e do cruzamento de variáveis. Resultados: Foram entrevistados 23 enfermeiros e 78 técnicos de enfermagem. Com relação à detecção de PCR, conduta imediata, ações de SBV e SAV, a maioria dos profissionais respondeu de maneira parcialmente correta. Conclusão: O baixo percentual de respostas totalmente corretas, evidencia a necessidade de atualização de toda a equipe de enfermagem, mantendo a uniformidade das condutas, melhorando assim o atendimento prestado ao paciente grave

Objetivo: Describir el conocimiento y actuación del equipo de enfermería de la urgencia del Hospital Universitario de la Universidad Federal del Valle del São Francisco de Petrolina / PE, ante el evento PCR. Métodos: Estudio cuantitativo, descriptivo y transversal por un muestreo no probabilístico de 101 profesionales de enfermería que respondieron a un cuestionario. Los datos fueron analizados por medio de la observación de las frecuencias de cada respuesta aislada y del cruce de variables. Resultados: Fueron entrevistados 23 enfermeros y 78 técnicos de enfermería. Con respecto a la detección de PCR, conducta inmediata, acciones de SBV y SAV, la mayoría de los profesionales respondió de manera parcialmente correcta. Conclusión: El bajo porcentaje de respuestas totalmente correctas, evidencia la necesidad de actualización de todo el equipo de enfermería, manteniendo la uniformidad de las conductas, mejorando así la atención prestada al paciente grave

A study on platelet reactivity and associated clinical characteristics in acute coronary syndrome patients treated with Ticagrelor and Clopidogrel

Background: The pathophysiology of the acute coronary syndrome (ACS) is characterized by the rupture of an atherosclerotic plaque within the coronary artery, with subsequent platelet aggregation, thrombus formation, and ischemia. Before platelets aggregate, they must first be activated to express activated glycoprotein IIb/IIIa receptors on the cell surface. This activation is the result of stimulation from endogenous platelet agonists, such as thromboxane A2 and adenosine diphosphate (ADP). ADP activates platelets by binding to P2Y12 receptors on the cell surface. Despite clinical efficacy in a broad range of coronary artery disease patients, pharmacodynamic studies conducted in patients undergoing stenting showed that clopidogrel therapy was associated with variable and moderate platelet inhibition (50% inhibition at steady state as demonstrated by ex-vivo ADP-induced platelet aggregation) as well. Ticagrelor, a cyclopentyl-triazolo-pyrimidine acting as an analog of adenosine triphosphate (ATP), constitutes a first non-thienopyridine direct platelet P2Y12 receptor blocker. Aim of the study: To investigate factors linked to HOTPR on ticagrelor and whether they differ from factors linked to HOTPR on clopidogrel. Materials and methods: Totally 300 patients were included in the study Patients presenting to the Department of Cardiology, SRM Medical College Hospital and Research Institute, Kattangulathur, Veeraraghavan Sriram, Venkatesh Munusamy, Dhandapani Vellala Elumalai. A study on platelet reactivity and associated clinical characteristics in acute coronary syndrome patients treated with Ticagrelor and Clopidogrel. IAIM, 2019; 6(8): 26- 34. Page 27 Kanchipuram District, Chennai with an ACS between January 2018 to May 2019 were eligible for inclusion in the study if coronary angiography (±PCI) was planned and they were adequately pretreated with Ticagrelor or clopidogrel and aspirin. An ACS was defined as symptoms suggestive of myocardial ischemia lasting > 15 min with either troponin elevation or new electrocardiogram (ECG) changes consistent with myocardial ischemia. ECG changes consistent with myocardial ischemia included ≥ 1 mm of ST-segment deviation or T wave inversion ≥ 1 mm in at least 2 contiguous leads. Troponin was considered elevated if greater than 14 ng/L, with a rise and/or fall of 50% if 14-50 ng/L or 20% if >50 ng/L in a subsequent measure. Results: The mean age was 63 ± 12 years with 71.9% being male and 18% having diabetes. Patients predominantly presented with NSTEMI 76% and 24% as STEMI. Patients treated with Ticagrelor were younger, more likely to be male, less likely to present with STEMI, have suffered a previous MI, experience atrial fibrillation and be taking proton pump inhibitors or calcium channel blockers. Patients who were administered Ticagrelor demonstrated significantly lower platelet reactivity when stimulated with ADP compared to patients administered clopidogrel (30.3 AU vs 43.7 AU respectively, p<0.0001). Conclusion: This study demonstrates that Ticagrelor provides more potent platelet inhibition than clopidogrel measured by MEA. This is reflected in ticagrelor’s ability to reduce the proportion of ACS patients experiencing HOTPR. Different clinical factors contribute to HOTPR in ACS patients treated with Ticagrelor or clopidogrel. Clopidogrel dose, renal insufficiency, clinical presentation, and platelet count are linked to clopidogrel HOTPR. In contrast, only a history of myocardial infarction is associated with Ticagrelor HOTPR.

Estudo dos critérios determinantes de procura pelo serviço de emergência, por pacientes classificados como pouco urgentes e não urgentes, em um hospital geral do sul do Brasil / Study of the determinant criteria for the search for the emergency department by patients classified as little urgent and not urgent, in a general hospital of the south of Brazil

Avaliar as características da demanda e os determinantes de procura pelo SE por pacientes classificados como pouco urgentes e não-urgentes em hospital geral, Sul do Brasil. Estudo epidemiológico, transversal. A coleta de dados foi realizada por entrevista, com duração aproximada de 15 minutos, em 2017, por pesquisadores treinados. Desfecho do estudo: determinantes de procura. Variáveis independentes: demográficas, socioeconômicas e características gerais de procura. Também coletou-se dados sobre a auto percepção do paciente (urgência e preocupação) e escolha do local para atendimento (Escala Likert 0-10). Os dados qualitativos apresentados na forma de frequências simples e relativa, os quantitativos como média e desvio padrão. Foram analisadas associações entre variáveis independentes e o desfecho, através do teste qui-quadrado de Pearson, seguido de Razão de Prevalência e Intervalo Confiança 95%. Participaram do estudo 290 pacientes: 50 (17%) pouco urgentes e 240 (83,0%) não urgentes, sexo feminino (57,2%), faixa etária entre 15-29 anos (39,0%), sem companheiro (51,0%), ensino superior/médio (69,3%), em atividade ocupacional (61,2%). Sobre características gerais da demanda: 77,9% oriundos de suas residências e 39,3% utilizou veículo próprio para o deslocamento. Distância média deslocamento (12,47±15,8 Km) e tempo médio deslocamento (25,98±23,55 minutos). Tempo médio triagem (17,69min.±15,36) e de espera atendimento médico (1h13min±1h10min). Não houve associação com significância estatística entre características demográficas, socioeconômicas e motivos de procura pelo SE. Conclui-se que os critérios determinantes de procura pelo SE foram resolutividade (40,9%) e funcionamento inadequado das UBS (24,7%), seguidos de procura por especialista e agudização da doença crônica.

To evaluate the demand and the determinants of the search for the Emergency service by patients classified as not very urgent and not-urgent in a general hospital, South of Brazil. Cross epidemiological study. Data collect was performed by interview, with an approximated duration of 15 minutes, in 2017, by trained researchers. Study outcome: Search determinants. Independent variables: demographic, socioeconomic and general demand characteristics. It was also collected data on the patient self-perception (urgency and concern) and the choice of the medical care (Likert Scale 0-10). The qualitative data presented by simple and relative way frequencies, the quantitative ones as average and standard deviation. Associations between independent variables and the outcome were analyzed using Pearson's chi-square test, followed by a Prevalence Ratio and 95% Confidence Interval. The study included 290 patients: 50 (17%) were not very urgent and 240 (83.0%) female not-urgent were (57.2%), 15-29 years old (39.0%), without partner (51.0%), higher /college degree (69.3%) in occupational activity (61.2%). On general demand characteristics: 77.9% come from their homes and 39.3% used their own vehicle for the trip. Average displacement distance (12.47 ± 15.8 Km) and average displacement time (25.98 ± 23.55 minutes). Average screening time (17.69min ± 15.36) and waiting for medical care (1h13min ± 1h10min). There was no association with statistical significance between demographic, socioeconomic and reasons for Emergency Service search. The determinant criteria of the search for ES were resolutiveness (40.9%) and inadequate working of the BHU (24.7%), followed by specialist search and chronic disease exacerbation.

Especialidad de Emergentología Pediátrica: ¡Bienvenida! / Pediatric emergency medicine specialty: Welcome!

La Emergentología Pediátrica se ha desarrollado en el mundo como una subespecialidad de la pediatría durante las últimas décadas. Los registros muestran una creciente necesidad de sus servicios. Esta orientación tuvo su empuje inicial en Estados Unidos de América y nuestro país ha continuado por el mismo camino, así como muchos otros países latinoamericanos. Aun así, habrá que intensificar su promoción y trabajar en el desarrollo de la investigación y la docencia relacionadas con el área para promover el bienestar de los niños, sus familias y de la sociedad en general.

Pediatric Emergency Medicine has developed around the world as a subspecialty of pediatrics. There is plenty of data reflecting a growing need for its services. The subspecialty was initiated in the United States and Argentina, together with other Latin American countries, followed the same path. Nevertheless, there is yet much to be done. It is necessary to strengthen its promotion and to stimulate research and teaching activities in order to continue improving the quality of care delivered to the pediatric population, their families and society as a whole.