Validation of the short form of the International Crowding Measure in Emergency Departments: an international study.

OBJECTIVE: There is little consensus on the best way to measure emergency department (ED) crowding. We have previously developed a consensus-based measure, the International Crowding Measure in Emergency Departments. We aimed to externally validate a short form of the International Crowding Measure in Emergency Department (sICMED) against emergency physician's perceptions of crowding and danger. METHODS: We performed an observational validation study in seven EDs in five different countries. We recorded sICMED observations and the most senior available emergency physician's perceptions of crowding and danger at the same time. We performed a times series regression model. RESULTS: A total of 397 measurements were analysed. The sICMED showed moderate positive correlations with emergency physician's perceptions of crowding, r = 0.4110, P < 0.05) and safety (r = 0.4566, P < 0.05). There was considerable variation in the performance of the sICMED between different EDs. The sICMED was only slightly better than measuring occupancy or ED boarding time. CONCLUSION: The sICMED has moderate face validity at predicting clinician's concerns about crowding and safety, but the strength of this validity varies between different EDs and different countries.

[Urinary tract dysfunction in older patients]. / La disfunción del tracto urinario inferior en el paciente mayor.

Urinary tract dysfunction in older patients has a multifactorial aetiology and is not a uniform clinical condition. Changes due to physiological ageing as well as comorbidity and polypharmacy, can produce several dynamic conditions such as urinary incontinence and urinary retention. Lower urinary tract symptoms increase with age in both sexes and are a major problem in older patients due to their medical and psychosocial consequences. For these reasons, in assessing urinary dysfunction in older patients, we should consider external circumstances such as polypharmacy, poor mobility, affective and cognitive disorders and also accessibility to housing.

La disfunción del tracto urinario inferior en el paciente mayor / Urinary tract dysfunction in older patients

La disfunción del tracto urinario inferior en los mayores suele ser multifactorial. Los cambios en el aparato urinario derivados del envejecimiento, junto con la comorbilidad y la polifarmacia, pueden ocasionar alteraciones dinámicas. Los síntomas del tracto urinario inferior aumentan con la edad, siendo un problema por sus consecuencias médicas y psicosociales. Por ello, en la valoración de la disfunción urinaria de los mayores hay que considerar aspectos como la polifarmacia, la movilidad, las alteraciones afectivas y cognitivas, y la accesibilidad a la vivienda (AU)

Urinary tract dysfunction in older patients has a multifactorial aetiology and is not a uniform clinical condition. Changes due to physiological ageing as well as comorbidity and polypharmacy, can produce several dynamic conditions such as urinary incontinence and urinary retention. Lower urinary tract symptoms increase with age in both sexes and are a major problem in older patients due to their medical and psychosocial consequences. For these reasons, in assessing urinary dysfunction in older patients, we should consider external circumstances such as polypharmacy, poor mobility, affective and cognitive disorders and also accessibility to housing (AU)

Evaluación diagnóstica del paciente con dolor lumbar en la unidad de emergencia / Diagnostic evaluation of patients with low back pain in the emergency unit

El dolor lumbar inespecífico constituye un grave problema desalud pública en todo el mundo. La prevalencia estimada a lolargo de la vida del dolor lumbar puede ser tan alta como 84%,y la prevalencia del dolor lumbar crónico es cercana a 23%, con11%-12% de invalidez debido a esta condición. Los pacientes conesta dolencia suelen consultar en el servicio de urgencia para suevaluación y tratamiento. Debido a que es un síndrome común conetiología y evolución generalmente benignas, el médico de urgenciaspuede pasar por alto los hallazgos clínicos que orientan a unaenfermedad grave. Este artículo revisa los elementos clínicos en laanamnesis y examen físico importantes a considerar, con énfasisen las señales de alerta de enfermedad grave. Las señales de alertapueden orientar al clínico en la evaluación diagnóstica, tratamientoespecífico y la derivación a un especialista de columna. Entre lasbanderas rojas a considerar, se incluyen el antecedente de traumasignificativo en relación a la edad, el déficit motor o sensorialprogresivo, la incontinencia urinaria o fecal de reciente aparición, la pérdida de tono del esfínter anal, anestesia en silla de montar,antecedentes de cáncer con metástasis ósea y la sospecha de infecciónespinal. En los pacientes sin elementos clínicos de riesgo o gravedad,el estudio diagnóstico por imágenes y los exámenes de laboratorio amenudo no son necesarios. Aunque existen numerosos tratamientospara el dolor lumbar agudo inespecífico, la mayoría tienen escasaevidencia que avale su costo-beneficio. La educación del paciente ylos medicamentos antiinflamatorios no esteroidales, paracetamol yrelajantes musculares son beneficiosos.

Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84 percent, and the prevalence of chronic low back pain is about 23 percent, with 11 percent-12 percent of the population being disabled by low back pain. Patients with low back pain commonly present in the emergency department for evaluation and treatment. Because it is a common syndrome with a generally benign origin, the examiner may overlook markers of serious disease. This article reviews the important historical and physical factors to consider, with an emphasis on the red flags of serious disease. Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age, major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required. Although there are numerous treatments for nonspecific acute low back pain, most have little evidence of benefit. Patient education and medications such as nonsteroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants are beneficial.

Enterococcal endocarditis on native and prosthetic valves: a review of clinical and prognostic factors with emphasis on hospital-acquired infections as a major determinant of outcome.

Enterococci are the third leading cause of infectious endocarditis, and despite advances in diagnosis and treatment, the mortality of enterococcal endocarditis has not changed in recent decades. Although variables such as advanced age, cardiac failure, and brain emboli have been recognized as risk factors for mortality, cooperative multi-institutional studies have not assessed the role of other variables, such as nosocomial acquisition of infection, the presence of comorbidities, or the changing antimicrobial susceptibility of enterococci, as factors determining prognosis.We conducted the current study to determine the risk factors for mortality in patients with enterococcal endocarditis in a single institution. We reviewed 47 consecutive episodes of enterococcal endocarditis in 44 patients diagnosed according to the modified Duke criteria from a retrospective cohort study of cases of infectious endocarditis. The main outcome measure was inhospital mortality. We applied stepwise logistic regression analysis to identify risk factors for mortality.Predisposing heart conditions were observed in 86.3% of patients, and 17 had prosthetic valve endocarditis. A portal of entry was suspected or determined in 38.2%; the genitourinary tract was the most common source of the infection (29.7%). Comorbidities were present in 52.2% of cases. Twelve episodes (25.5%) were acquired during hospitalization. Only 3 isolates of Enterococcus faecalis were highly resistant to gentamicin. Eighteen patients (40.9%) needed valve replacement due to cardiac failure or relapse. Comparing cases of native valve and prosthetic valve endocarditis, we found no differences regarding complications, the need for surgical treatment, or mortality. Eight of 44 (18%) episodes were fatal. Age over 70 years (p = 0.05), heart failure (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.15-2.25; p = 0.001), presence of 1 or more comorbidities (OR, 3.2; 95% CI, 1.11-9.39; p = 0.02), and nosocomial acquisition (OR, 8.05; 95% CI, 1.50-43.2; p = 0.01) were associated with mortality. In the multivariate analysis, only nosocomial acquisition increased the risk of mortality. In patients with enterococcal endocarditis, nosocomial acquisition of infection is an important factor determining outcome. As the incidence of bacteremia and the population of elderly people at risk continue to grow, the hazard of acquiring nosocomial enterococcal endocarditis may increase; hence, major emphasis must be put on prevention.