Diagnostic accuracy of combining C-Reactive protein and Alvarado Score among 2-to-20-year-old patients with acute appendicitis suspected presenting to Emergency Departments.

OBJECTIVE: Main objective was whether the combination of C-Reactive Protein (CRP) and Alvarado Score (AS) increase the diagnosis accuracy of AS among 2-to-20-year-old patients with suspected acute appendicitis presenting to Emergency Departments. METHODS: This is a secondary analysis of prospective cohort study consecutively including all patients from 2 to 20 years of age attended for suspected acute appendicitis in 4 Spanish Emergency Departments during 6-month period. We collected demographic, clinical, analytic and radiographic, and surgical data. AS categories were retrospectively calculated as low (0-4 points), intermediate (5-6 points) or high (7-10 points). The cut-off levels were >0.5 mg/dl for CRP. The outcome was diagnosis of acute appendicitis within 14 days of the index visit. RESULTS: A total of 331 patients with suspected of acute appendicitis (mean age 11.8 (SD 3.8) years; 52.9% males) were recruited. According to AS, 108 (32.6%) were at low risk, 76 at (23.0%) intermediate risk and 147 (44.4%) at high risk of acute appendicitis. One hundred and sixteen (35.0%) cases had confirmed histopathological diagnosis of acute appendicitis. The AUCs of ROC were 0.76 (0.70-0.81) for AS and 0.79 (95% CI 0.75-0.84) for CRP-AS being the difference statistically significant (p=0.003). The CRP for diagnosis acute appendicitis in low risk AS group had negative predictive value of 95.8% (95%CI 87.3-98.9) and likelihood ratio negative of 0.4 (95%CI 0.2-1.0).. CONCLUSIONS: CRP-AS has shown to increase the diagnostic accuracy of AS for acute appendicitis. This approach may be useful to rule out the diagnosis of acute appendicitis in paediatric patients attended for abdominal pain suggestive of acute appendicitis.

Docencia en medicina de urgencias y emergencias / Teaching in emergency medicine

de urgencias y emergencias puede llegar a ser losuficientemente complejo como para requerir una sólidaformación que debiera estar sustentada en una especialidadmédica, como ocurre en la mayoría de paísesde nuestro entorno.En la actualidad, en España no existe una formaciónreglada y homogénea en medicina de urgencias y emergencias(MUE) ni durante el período de formación de pregrado(en forma de asignatura obligatoria de forma universalen las facultades de medicina) ni durante el períodode posgrado (en forma de especialidad médica). En estesentido, actualmente se está pendiente de la aprobacióndefinitiva de esta especialidad en MUE en el marco de unareforma del programa de residencia que evolucionará haciaun programa formativo troncal de especialidades. A laespera de ello, la realidad es que en España los profesionalesque desarrollan su labor en este ámbito asistencialposeen una formación heterogénea. Fruto de todo estevacío y de las necesidades formativas de estos profesionales,se ha desarrollado con los años un amplio abanicode propuestas formativas específicas para optimizar lashabilidades y destrezas de los profesionales que prestanla primera asistencia urgente a los pacientes.Una nueva generación de cursos se ha puesto enmarcha utilizando las nuevas metodologías didácticasde formación, en las que se incorporan herramientasdidácticas de e-learning y simulación robótica(AU)

The appropriate care of patients in emergency servicescan reach a level of complexity as to make a soundtraining necessary, which should be based on a medicalspeciality, as happens in the majority of the countriesin our context.In Spain at present there is no regulated and homogeneoustraining in urgency and emergency medicine(UEM), either during the period of undergraduate training(in the form of a universally compulsory subjectin the faculties of medicine) or during the postgraduateperiod (in the form of a medical speciality). In this respect,the definitive approval of the speciality in UEM iscurrently pending within the framework of a reform ofthe residence program that will evolve towards a coretraining program of specialities. Until thus occurs, thereality in Spain is that professionals who work in thiscare setting possess a heterogeneous training. As a resultof this vacuum and the training needs of these professionals,a wide range of specific training proposalshas been developed over the years in order to optimisethe skills and abilities of the professionals who provideinitial emergency care to the patient.A new generation of courses has been set underwayusing the new didactic methodologies of training,into which didactic tools of e-learning and roboticsimulation have been incorporated(AU)

Prostaglandina E2 intracervical (Prepidil) frente a dispositivo vaginal (Propess) en la maduración cervical e inicio del parto. Estudio comparativo / Comparative study of intracervical prostaglandin E2 (Prepidil) versus vaginal insert (Propress) in labor induction

Objetivo. Comparar la eficacia y seguridad de un gel de prostaglandina E2 (PGE2) intracervical (Prepidil) con la de un dispositivo vaginal de PGE2 (Propress), para la maduración cervical y la inducción de parto. Material y métodos. Un total de 200 gestantes con test de Bishop desfavorable (< 6) y que precisaban inducción de parto fueron seleccionadas en el contexto de un muestreo no probabilístico de casos consecutivos y tratadas con PGE2. Cien gestantes recibieron una dosis de PGE2 intracervical que se repitió a las 24 y 48 h si el cérvix permanecía desfavorable. Si pasadas 48 h de la dosis inicial el parto no se había desencadenado, se procedía a la amniotomía e inducción oxitócica. Del mismo modo, se procedía con otras 100 mujeres a las que se aplicó PGE2 en dispositivo vaginal. Se valoraron las características de las gestantes, el número de aplicaciones, el intervalo entre la aplicación y el comienzo del parto, el tipo de parto, el resultado perinatal y los efectos secundarios. Para la comparación estadística de resultados se utilizó el paquete informático SPSS 10,0, y se consideraron significativos valores de p < 0,05. Resultados. Las características de las pacientes fueron similares, lo que permite que la comparación sea exacta. En el 76% de los casos tratados con gel intracervical, el trabajo activo de parto comenzó tras la primera aplicación, frente al 78% de los casos en que se utilizó el dispositivo vaginal. Ambos procedimientos se mostraron más eficaces en multíparas que en nulíparas. En el 55% de los casos, el intervalo entre la aplicación del gel intracervical y el comienzo del parto fue < 12 h, frente al 40% de los casos en que se aplicó el dispositivo vaginal. No obstante, el intervalo medio entre uno y otro procedimiento apenas mostró diferencias: 17,06 h para el gel y 18,46 h para el dispositivo vaginal. Este intervalo fue menor para ambos procedimientos en las multíparas (10,82 frente a 15,40 h). La tasa de cesáreas fue del 27% para el gel intracervical y del 24% para el dispositivo vaginal. Esta diferencia no fue estadísticamente significativa. En el primer grupo se practicaron un 5% de cesáreas por fracaso de inducción y un 3% en el segundo. Una segunda aplicación se asoció a una mayor tasa de cesáreas, siendo el porcentaje mayor en el grupo tratado con gel intracervical con diferencias estadísticamente significativas (p < 0,005). En los 2 procedimientos utilizados, la cesárea fue más frecuente en nulíparas que en multíparas, con diferencias significativas en el grupo del dispositivo vaginal, si bien estas diferencias no llegaron a ser significativas en el grupo de gel intracervical debido al escaso número de multíparas en este grupo. El resultado perinatal y los efectos secundarios no mostraron diferencias en los 2 grupos estudiados. Conclusión. Ambas formas de PGE2 son seguras y eficaces, si bien la aplicación del dispositivo vaginal se asocia a una menor tasa de cesáreas cuando es necesaria una segunda aplicación, lo que puede estar en relación con una menor tasa de cesáreas por fracaso de inducción con respecto al gel intracervical y la mayor paridad en este grupo. Si a ello se une la facilidad para su colocación y retirada, es evidente que el dispositivo vaginal es una alternativa fiable para la maduración cervical e inducción del parto (AU)

Objective. To compare the efficacy and safety of prostaglandin E2 (PGE2) intracervical gel (Prepidil) with that of PGE2 vaginal insert (Propress) in cervical ripening and labor induction. Material and methods. Two hundred pregnant women with unfavorable Bishop's scores (< 6) requiring induction of labor were selected through nonprobabilistic sampling of consecutive cases. All the women were treated with PGE2. One-hundred pregnant women received an intracervical PGE2 dose, which was repeated 24 and 48 hours later if the cervix remained unfavorable. If labor was not induced 48 hours after the initial dose, amniotomy was performed and oxytocin was administered. The same procedures were performed in another 100 women who were administered PGE2 through a vaginal insert. The characteristics of the pregnant women, the number of applications, the interval between the applications and the beginning of labor, type of delivery, perinatal outcomes, and adverse effects were evaluated. For the statistical comparison of results, the SPSS 10.0 statistical package was used. Values of p < 0.05 were considered significant. Results. The patients' characteristics were similar, allowing exact comparisons. Active labor began after the first application of PGE2 in 76% of the patients treated with intracervical gel compared with 78% of those with the vaginal insert. Both procedures proved to be more effective in multiparas than in nulliparas. The interval between PGE2 application and the beginning of labor was less than 12 hours in 55% of the group with intracervical gel compared with 40% of the group with the vaginal insert. Nevertheless, the mean interval between the two procedures showed minimal differences: 17.06 hours for the gel and 18.46 hours for the vaginal device. With both procedures, this interval was lower in multiparas than in nulliparas (10.82 hours versus 15.40 hours). The rate of caesarean section was 27% in women with intracervical gel and 24% in those with the vaginal device. This difference was not statistically significant. Five percent of cesarean sections were performed for failure of induction in the group with intracervical gel compared with 3% in the group with the vaginal device. A second application was associated with a higher rate of caesarean section; the highest percentage was found in the group treated with intracervical gel, with statistically significant differences (p < 0.005). With both procedures, cesarean section was more frequent in nulliparas than in multiparas, with statistically significant differences in the vaginal insert group; however, in the intracervical gel group these differences did not reach statistical significant due to the small number of multiparas in this group. No significant differences were found between the two groups in perinatal outcomes or adverse effects. Conclusion. Both forms of PGE2 are safe and effective, although the vaginal insert was associated with a lower rate of caesarean section when a second application was required. This finding could be related to the lower rate of cesarean section for failure of induction and to the higher parity in the vaginal insert group. In view of these results and the ease of placement and withdrawal of the vaginal device, this alternative is a valid option for cervical ripening and labor induction (AU)

Embarazos gemelares espontáneos frente a reproducción asistida / Spontaneous versus assisted conception multiple pregnancies

Objetivos: Puesto que las gestaciones gemelares y múltiples son un importante problema de las técnicas de reproducción asistida (TRA), parece necesario aportar una experiencia más en el conocimiento de la existencia o no de diferencias entre ambos tipos de embarazo. Material y métodos: Nuestro estudio, realizado de forma retrospectiva, incluye todos los partos gemelares y múltiples (> 22 semanas) habidos en el Hospital General Yagüe de Burgos entre el 1 de enero de 1998 y el 31 de diciembre del 2003. Hubo un total de 156 partos gemelares, de los cuales 116 (74,3%) fueron debidos a concepción natural y 40 (25,6%) conseguidos tras TRA. En el tratamiento estadístico de los datos, obtenidos de las correspondientes historias clínicas, se utilizó la prueba *2 para la comparación de variables cualitativas y el análisis de la varianza para la comparación de medias. Los resultados cuantitativos se expresaron en X­ ± desviación estándar. Se utilizó el paquete informático SPSS 10,0, y se consideraron significativos valores de p < 0,05. Resultados: Los resultados conseguidos tras TRA corresponden a mujeres con una media de edad mayor y más baja paridad que los embarazos espontáneos, con diferencias estadísticamente significativas. El porcentaje de cesáreas en gestaciones conseguidas con tratamiento fue del 85 frente al 55% de las espontáneas, diferencias que fueron estadísticamente significativas. A pesar de no haberse observado diferencias en las complicaciones obstétricas habidas durante la gestación, en las semanas de gestación y en el peso de los recién nacidos, el resultado perinatal (mortalidad perinatal y malformaciones congénitas) fue peor en los embarazos conseguidos con tratamiento, si bien las diferencias no llegaron a ser estadísticamente significativas. Conclusiones: En nuestro estudio los embarazos gemelares y múltiples con TRA mostraron un mayor número de cesáreas y peor resultado perinatal que los espontáneos, y ello, dado que no hubo diferencias en las complicaciones obstétricas, ha de relacionarse con la mayor edad y la más baja paridad de aquellas, que justifican, por otra parte, las TRA (AU)

Objectives: Because multiple pregnancies are an important problem in assisted reproduction technologies, we investigated whether there are differences between these types of pregnancy. Material and methods: We performed a retrospec-tive study of all multiple deliveries (> 22 weeks) in the General Yagüe Hospital between January 1, 1998 and December 31, 2003. There was a total of 156 multiple deliveries. Of these 116 pregnancies (74.3%) were spontaneous and 40 (25.6%) were achieved after assisted reproduction technologies. Data were obtained from the patients' clinical histories. The chi-squared test was used to compare qualitative variables and analysis of variance was em ployed to compare means. Quantitative results are expressed as mean ± standard deviation. Data were processed using the SPSS 10.0 statistical package and the level of significance was set at p < 0.05. Results: Mean age was significantly higher and parity was significantly lower in women who became pregnant after undergoing assisted reproduction technologies than in those with spontaneous pregnancies. The cesarean section rate was significantly higher in women who underwent assisted reproduction technologies than in those with spontaneous pregnancies (85% vs 55%, respectively). No significant differences were observed in obstetric complications during pregnancy or in neonatal birth weight. However, perinatal outcomes (perinatal mortality and congenital malformations) were worse in women who underwent assisted reproduction technologies, although these differences were nonsignificant. Conclusions: In this study, the cesarean section rate was higher and perinatal outcomes were less favorable in multiple pregnancies achieved after assisted reproduction technologies than in spontaneous multiple pregnancies. Since no differences were found in obstetric complications, these results were associated with the greater age and lower parity of women undergoing these techniques which, in turn, justify their use (AU)

Autotratamiento de la insuficiencia suprarenal de origen hipofisario / Autotreatment of adrenal deficiency of pituitary source

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Quiste aracnoideo en paciente con SIDA y clínica neurológica / Arachnoid cyst in patient with AIDS and neurologic disease

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Myotrophic effects of muscle extracts obtained at different intervals after denervation.

A study was made of the myotrophic effects of denervated muscle extracts on normal Wistar rat soleus muscle. Extracts obtained 1 h, 2, 4 and 7 days after sectioning of the sciatic nerve were administered intraperitoneally over five consecutive days. Soleus muscles were routinely processed for morphological and morphometrical analysis using light microscopic techniques. Quantitative differences were observed in the effects of different extracts on total muscle area, fibre cross-sectional area, mean minimum diameter and number of fibres/ area. The greatest myotrophic response was elicited by extracts obtained at 2 and 4 days; differences with respect to controls and extracts obtained at 1 day were significant (P < 0.05) for all parameters studied. Statistically significant differences (P < 0.05) were also recorded for fibre cross-sectional area and mean minimum diameter between the 2- and 4-day groups and the 7-day group. It may thus be concluded that the time elapsing between denervation and extract obtention influences the effect of the extract on normal rat muscle.