[Emergency department overcrowding: a legitimate reason to refuse access to urgent care for non-urgent patients?]. / Engorgement des centres d'urgences: une raison légitime de refuser l'accès aux patients non urgents?

Non-urgent cases represent 30-40% of all ED consults; they contribute to overcrowding of emergency departments (ED), which could be reduced if they were denied emergency care. However, no triage instrument has demonstrated a high enough degree of accuracy to safely rule out serious medical conditions: patients suffering from life-threatening emergencies have been inappropriately denied care. Insurance companies have instituted financial penalties to discourage the use of ED as a source of non-urgent care, but this practice mainly restricts access for the underprivileged. More recent data suggest that in fact most patients consult for appropriate urgent reasons, or have no alternate access to urgent care. The safe reduction of overcrowding requires a reform of the healthcare system based on patients' needs rather than access barriers.

[An efficient example of a Swiss pre-hospital chain of survival: the state of Vaud model]. / La chaîne des secours: le modèle vaudois.

The state of Vaud model of the pre-hospital chain of survival is an example of an efficient way to deal with pre-hospital emergencies. It revolves around a centrally located dispatch center managing emergencies according to specific key words, allowing dispatchers to send out resources among which we find general practitioners, ambulances, physician staffed fast response cars or physician staffed helicopters and specific equipment. The Vaud pre-hospital chain of survival has been tailored according to geographical, demographical and political necessities. It undergoes constant reassessment and needs continuous adaptations to the ever changing demographics and epidemiology of pre-hospital medicine.

[Pre-travel advice for the elderly]. / Voyâge: comment preparer tes personnes âgées au voyage.

The aging population, the multiplication of leisure activities and the many possibilities to travel will confront the primary care physician to elderly travelers who want health advice prior to their journey, sometimes in remote areas. Age itself is no contra-indication to travel, but the co-morbidities and the potential upsets that the elderly can be submitted to might render her/him more vulnerable to health problems. A medical evaluation, specific recommendations about traveling (including sufficient medication and medical material) and a medical certificate should be proposed by the primary care practitioner to her/his elderly patient planning to travel.

Immunogenicity and reactogenicity of a combined hepatitis A and B vaccine in healthy Chilean subjects.

OBJECTIVES: A combination vaccine against hepatitis A and B provides the opportunity for simultaneous protection against both diseases with a single vaccine. This clinical study investigated the reactogenicity and immunogenicity of a combined hepatitis A and B vaccine (Twinrix, GlaxoSmithKline Biologicals, Rixensart, Belgium) in healthy Chilean adults between 18 and 40 years of age. METHODS: In total, 345 healthy, seronegative health care workers were enrolled and randomized to three groups who received one of three lots of Twinrix on a 0-, 1- and 6-month schedules. Blood samples were screened 1 month after each dose for anti-HAV and anti-HBs antibodies. Reactogenicity after each dose was assessed using diary cards. RESULTS: The nature and incidence of symptoms were similar to those reported for other Twinrix studies. Very few symptoms were scored as severe. Upon completion of the vaccination, all subjects had anti-HAV antibodies with titers $6000 mIU/mL, and all but one were protected against hepatitis B, with titers $4000 mIU/mL. CONCLUSIONS: We have demonstrated the high immunogenicity and tolerance of the combined hepatitis A and B vaccine. Combined vaccination has the advantage of offering dual protection with a reduction in the number of injections needed, lower associated costs, and a positive impact on compliance.

Vaccination against hepatitis A in children aged 12 to 24 months [corrected].

BACKGROUND: Current hepatitis A vaccines are either licensed for children >2 years of age, as in the U.S. or Chile, or >1 year of age, as in Europe and other parts of the world. Recent recommendations for immunization against hepatitis A have included routine vaccination of children in areas or regions of higher endemicity. However, data on hepatitis A vaccination in toddlers aged between 1 and 2 years are scarce. METHODS: This open clinical study investigated the reactogenicity and immunogenicity of two doses (0, 6-month schedule) of an inactivated hepatitis A vaccine (Havrix pediatric, Glaxco SmithKline Biologicals, Rixensart, Belgium) in 120 seronegative children aged 12-24 months. RESULTS: Pain at the injection site and irritability were the most frequently reported local and general symptoms, respectively. No serious adverse events related to the study vaccine were reported. One month after the first dose, all but one subject had antibodies against hepatitis A with a GMT of 159 mIU/mL. After the booster dose, all had antibodies with a GMT of 2,939 mIU/mL. CONCLUSIONS: Our data show that the inactivated hepatitis A vaccine was well tolerated by these toddlers and that the vaccine elicits a good immune response.

[Complications in children with varicella in 4 hospitals in Santiago, Chile: clinical spectrum and estimation of direct costs]. / Complicaciones en niños con varicela en cuatro hospitales de Santiago-Chile: espectro clínico y estimación de costos directos.

BACKGROUND: The knowledge of varicella complications and their associated cost may help for a better evaluation of varicella immunization benefits. AIM: To determine frequency, type, outcome and affected population of varicella complications in children requiring hospitalization, and to estimate their direct costs. MATERIAL AND METHODS: Retrospective analysis of medical records of children admitted to four hospitals in Santiago, Chile, due to varicella complications between January 1997 and February 1999. Calculation of direct costs of hospitalizations in a sample of 30 patients. RESULTS: One hundred fifty four patients were identified, 74% were younger than 5 years old, only one was immunocompromised. Complications identified were skin and soft tissue infections in 63%, invasive infections in 25.3%, neurological in 7.1% and miscellaneous in 4.5%. Staphylococcus aureus and Group A beta-haemolytic Streptococcus (GABS) were predominantly isolated. S. aureus was the main agent identified in superficial infections and GABS in invasive infections (sterile sites). Two patients died due to invasive infections (streptococcal toxic shock and S. aureus septicaemia) and 11 required surgical procedures. The average cost per hospitalization was US$ 600 in public hospitals and US$ 1,800 in the private hospital. CONCLUSIONS: Varicella complications requiring hospitalization are due mainly to bacterial infections and they affect immunocompetent toddlers. These complications can be severe and even fatal.

Hepatitis A in Latin America: a changing epidemiologic pattern.

In a multicenter study, hepatitis A virus (HAV) seroprevalence was surveyed in six countries in Latin America in which in 12,000 subjects were stratified for age. The highest rates of seroprevalence were recorded in the Dominican Republic (89.0%) and Mexico (81.0%), with lower rates in Brazil (64.7%), Chile (58.1%), Venezuela (55.7%), and Argentina (55.0%). The seroprevalence of HAV in children between 1 and 5 years of age was less than 50%, except in the Dominican Republic. In the 5-10-year-old age group, seroprevalence rates have also decreased compared with previous reports. This suggests that the epidemiology is shifting from high to intermediate endemicity, with the population susceptible to HAV infection shifting from children to adolescents and adults. Furthermore, data from Brazil, Argentina, and Mexico show that HAV seroprevalence is significantly lower in people living in medium and high socioeconomic conditions. This study suggests the need for appropriate vaccination programs to be implemented targeting children, adolescents, and adults, particularly in higher socioeconomic groups.

[Serum antibodies against hepatitis A virus among subjects of middle and low socioeconomic levels in urban area of Santiago, Chile]. / Anticuerpos séricos contra el virus hepatitis A en sujetos de nivel socioeconómico medio y bajo, en comunas urbanas de Santiago.

BACKGROUND: The epidemiology of hepatitis A virus (HAV) infection is closely associated to the level of hygiene and sanitation of the population. Newly industrialising areas experience a transition from high to intermediate endemicity, which is characterized by a shift in the exposure age to HAV, from early childhood to school ages or adolescence. AIM: To measure the prevalence of HAV antibodies in subjects living in urban Santiago. SUBJECTS AND METHODS: A HAV antibody survey in five medium and low socioeconomic level urban districts of northern Santiago, was conducted in 1996. Healthy subjects aged 1 to 39 years old were recruited from randomly selected households. RESULTS: Five hundred three subjects were studied. Anti HAV antibodies were found in 13.2, 29.5, 59.6, 78.1, 95.6 and 98.2% of individuals aged 1 to 4, 5 to 9, 10 to 14, 15 to 19, 20 to 29 and 30 to 39 years old, respectively. CONCLUSIONS: The profile of positive antibodies is compatible with an intermediate pattern of transmission of HAV. The current data supports the idea that infection is shifting towards older ages. A progressive increase in the number of susceptible school age children and teenagers is propitious for the occurrence of common source hepatitis A outbreaks.

[Current status of immunity to hepatitis A virus in various adult groups]. / Estado actual de inmunidad para hepatitis por virus A en diversos grupos de adultos.

BACKGROUND: As sanitary and economic conditions improve, the prevalence of antibodies to hepatitis A is now significantly lower. AIM: To evaluate the prevalence of hepatitis A virus antibodies in healthy Chilean adults. MATERIAL AND METHODS: Antibodies to hepatitis A virus were measured, using a commercial ELISA assay, in 215 voluntary blood donors (163 male, aged 19 to 30 years old) and 295 medical students and health personnel (156 male, aged 19 to 39 years old), residing in Valdivia, Chile. RESULTS: Antibodies against hepatitis A virus were found in 68.2% of the total sample (351/510). Ninety percent of flood donors and 54% of health personnel and students were positive (p < 0.01). Age specific prevalence in blood donors 19 to 22, 23 to 29 and 27 to 30 years old was 81.0%, 95.2% and 95.6% respectively. Among the same age groups in medical students, the prevalence was 47.9%, 53.2% and 61.9% respectively (p < 0.01). CONCLUSIONS: This study indicates a reduction in the prevalence of hepatitis A virus antibodies among adults in Valdivia (Chile). Differences detected between individuals are probably related to different socioeconomic levels. Medical students have an increased risk for hepatitis A infections than the general population.

Extracellular polysaccharides from Xanthomonas axonopodis pv. manihotis interact with cassava cell walls during pathogenesis.

The location of lipopolysaccharides produced by Xanthomonas axonopodis pv. manihotis during pathogenesis on cassava (Manihot esculenta) was determined by fluorescence and electron microscopy immunolabeling with monoclonal antibodies. During the early stages of infection, pathogen lipopolysaccharides were detected on the outer surface of the bacterial envelope and in areas of the plant middle lamellae in the vicinity of the pathogen. Later in the infection process, lipopolysaccharide-specific antibodies bound to areas where the plant cell wall was heavily degraded. Lipopolysaccharides were not detected in the fibrillar matrix filling intercellular spaces of infected cassava leaves. Monoclonal antibodies specific for the exopolysaccharide xanthan side chain labeled the bacteria, the fibrillar matrix, and portions of the host cell wall. The association of Xanthomonas lipopolysaccharides with host cell walls during plant infection is consistent with a role of these bacterial extracellular polysaccharides in the infection process.

Efficacy of a vancomycin solution to prevent bacteremia associated with an indwelling central venous catheter in neutropenic and non-neutropenic cancer patients.

We evaluated the efficacy of a vancomycin solution in the prevention of bacteremia caused by vancomycin-sensitive organisms (VSO) in cancer patients with a tunneled central venous catheter (CVC). Eighty-three patients who had a single lumen CVC were randomized to use a heparin solution (25 U/ml) for daily catheter flush with (HepVan) or without (Hep) vancomycin, 25 mcg/ml. Febrile episodes were recorded, and central and peripheral blood cultures were drawn before beginning antibiotic therapy. Patients participated in follow-up to 16,677 catheter days (8,666 Hep and 8,011 HepVan), and 143 febrile episodes were recorded (82 Hep and 61 HepVan). Forty-four episodes of bacteremia occurred, 23 of them due to VSO (16 occurred in the Hep group and 7 in the HepVan group (P = 0.19). VSO bacteremia occurred in 14 neutropenic (absolute neutrophil count < 500 x 10(9)/l) episodes (7 Hep vs. 7 HepVan) and in 9 non-neutropenic episodes (9 Hep vs. O HepVan; P = 0.013). Vancomycin effectively prevented bacteremia by VSO in non-neutropenic patients, supporting the idea that intraluminal colonization of indwelling CVCs contributes to bacteremia only in these patients.

[Lactic acidosis and hyperlactatemia]. / Acidose lactique et hyperlactatémie.

Lactic acidosis is a relatively frequent acid-base disorder in a hospital setting. It is defined by the association of an arterial pH inferior to 7.35 and an arterial lactate level superior to 5 mmol/l. Classically, 2 types of acidosis are distinguished on the basis of their mechanisms of onset: the type A, with evident clinical signs of tissue hypoperfusion and the type B, more are, without apparent hypoxia. This last category is observed in various circumstances such as diabetes, acute liver failure, poisoning and, more rarely, inborn errors of carbohydrate metabolism. Treatment aims primarily at the correction of the cause. The efficacy of sodium bicarbonate is presently debated, considering the risk to worsen hyperlactatemia and to induce hyperosmolarity or rebound alkalosis. The administration of dichloroacetate, an activator of pyruvate dehydrogenase, permits to correct partially the lactic acidosis but is not harmless especially in case of prolonged administration. Other therapeutic modalities are evoked. Arterial lactate level is a reliable prognostic index of shock, because blood values do not depend only of the oxygen debt but also of the efficacy of hepatic and renal lactate uptake. Sequential measurements are recommended.

Consideraciones generales sobre evaluacion del estado nutricional. / General considerations on the evaluation of nutritional status

Se enfatizam las repercusiones de la desnutricion, sea calorica-proteica (marasmo o caquexia) sea proteica pura (kwashiorkor), sobre la capacidad de defensa y recuperacion de los pacientes y, por ende, de su pronostico. La desnutricion, en sus diversos grados, existe en el 30 a 50% de los adultos que se hospitalizan. Por ello cada paciente debe ser objeto de una evaluacion y de un plan nutricional que puede o no implicar asistencia nutricional. Esta puede ser no intensiva o intensiva (enteral o parenteral, parcial o total). Se enumeran las ventajas relativas de la alimentacion enteral. Se establecen y describen los principales parametros antropometricos, bioquimicos, inmunologicos y citologicos en los que se fundamenta la evaluacion del estado nutricional: reserva calorica (depositos grasos); reverva proteica (muscular y visceral); grado de catabolismo. Esta evaluacion debe complementarse, en todos los casos con el estudio de la suficiencia respiratoria, hepatica y renal

Alimentacion enteral. / Enteral alimentation

Se destallan las indicaciones y las principales contraindicaciones de la alimentacion enteral, asi como los niveles de soporte nutricional requeridos en diversas circunstancias clinicas.Se senalan las bases que permiten calcular los aportes caloricos, proteico, glucidico, lipidicos y de vitaminas y minerales. Con respecto al aporte calorico, este se determina precisando el gasto energetico basal. Para ello se utiliza la formula propuesta por Harris y Benedict. Los valores ostentan diferencias atribuibles al sexo y deben corregirse segun el grado de actividad fisica; la patologia existente y al estado del metabolismo. Se describe la tecnica de intubacion con o sin control fluoroscopico y el tipo de sondas disponibles.Se analisan las caracteristicas de las mezclas nutritivas disponibles y la forma de administrarlas.Finalmente se destacan las posibles complicaciones del procedimiento, mencionando las mecanicas; gastrointestinales y metabolicas

[Factitious fevers as a cause of prolonged fevers. Apropos of 5 clinical cases]. / Fièvres factices comme cause de fièvres prolongées. A propos de 5 observations.

Among the numerous causes of prolonged fever of unknown origin, the factitious fevers are frequently considered last after much diagnostic and therapeutic effort. Five observations of factitious fever are presented including 2 cases of thermometer manipulation in men aged 45 and 80. The latter patient is the oldest in whom such a case has been reported. In the first case the prolonged fever led to exploratory laparotomy with splenectomy followed by antilymphoma chemotherapy before the thermometer manipulation was discovered. This patient had previously been treated successfully for stage Ib Hodgkin lymphoma. In the other case hospitalization had lasted several weeks, and much antibiotic and steroid treatment had been administered, before the manipulation was suspected. A third case of thermometer manipulation was observed in a 57-year-old woman who had been presenting with factitious symptoms for over 10 years. Two other cases of factitious fever due to self-induced infections have been observed in two young women aged 23 and 27, both in paramedical professions. These self-induced infections led to polymicrobial bacteremia, exploratory laparotomy and hemicolectomy in one case, and to probable bacterial meningitis in the other. Certain aspects of these cases agree well with the diagnostic criteria of factitious fever described in the literature. We feel it is important to recognize this cause of febrile states, even if there is an apparent etiology, in order to avoid much vain investigation and prolonged hospitalization.