Seguridad en urgencias sobre la referencia de pacientes no urgentes a centros de atención primaria / Safety of referral of patients with non-urgent conditions from the emergency room to primary care centers

Objetivos: determinar la seguridad al referir pacientes triage 4 y 5 desde un servicio de urgencias a centros de atención primaria, conociendo su disposición final y las posibles complicaciones por esta estrategia. Métodos: estudio observacional retrospectivo de 333 pacientes clasificados como triage 4 y 5 que fueron referidos desde el servicio de urgencias a un centro de atención primaria en febrero 2019. A través de la aseguradora se obtuvo la información sobre si asistieron o no a dicha cita programada y la conclusión final de la consulta. Resultados: 52 pacientes (15,6%) no asistieron a la cita programada sin que esto causara alguna complicación para su salud. De los 281 que sí asistieron, 1,4% fueron referidos a valoración especializada urgente sin que requirieran ingreso hospitalario y 98,6% fueron atendidos y manejados en forma ambulatoria por el médico de atención primaria. Se encontraron diferencias entre los no asistentes a la atención primaria en los subgrupos de edad entre 3 a 17 (p=0,009) y 18 a 37 años (p=0,04). Conclusiones: la estrategia de referencia de pacientes clasificados en 4 o 5 desde un servicio de urgencias a centros de atención primaria es segura, incluso si estos no asisten a la cita programada

Objectives: to determine the safety of referral of triage category 4 and 5 patients from the emergency room to primary care centers, aware of their final disposition and the potential complications of this strategy. Methods: a retrospective observational study of 333 triage category 4 and 5 patients who were referred from the emergency room to a primary care center in February 2019. Information on scheduled appointment attendance, and final consultation diagnosis was obtained from the insurer. Results: 52 patients (15.6%) failed to attend their scheduled appointment presenting no health complications. Of the 281 who attended their clinic appointment, 1.4% were referred for urgent specialist consultation without requiring hospital admission. The primary care physician provided care and management to 98.6% of studied patients on an outpatient basis. Differences were found among those failing to attend primary care in the 3 to 17 (p=0.009) and 18 to 37 years (p=0.04) age subgroups. Conclusions: triage category 4 and 5 patients referral strategy from the emergency service to primary care centers is safe, even if patients fail to attend their scheduled appointment

[Neuroendocrine small-cell carcinoma of the gallbladder. An unexpected finding after diagnostic laparoscopy]. / Carcinoma neuroendocrino de células pequeñas de vesícula biliar. Un hallazgo inesperado con el uso de laparoscopia diagnóstica.

BACKGROUND: Gallbladder cancer ranks fifth among oncological diseases affecting the gastrointestinal tract; nevertheless, it is the world's most common malignant tumor of the bile ducts. It is usually diagnosed after cholecystectomy and tends to have bad prognosis. Adenocarcinoma is the main histological finding, although other rare histologic types have been described among the actual literature. Poorly differentiated squamous-cell neuroendocrine gallbladder carcinoma is an extremely rare neoplasm. A poor prognosis is associated with this histological type. AIM: The aim of this paper is to show that performing a systematic exploration of the entire peritoneal cavity in all laparoscopic surgeries can lead to find completely unexpected changes related to an unidentified disease. Also, a detailed review of our unexpected finding is made: The neuroendocrine small cell carcinoma of gallbladder. CLINICAL CASE: We hereby report the case of a 40-year-old patient with a ruptured ectopic pregnancy that underwent emergency laparoscopic surgery, presenting the incidental finding of a small-cell carcinoma of the gallbladder. CONCLUSIONS: Our surgical group advised that by introducing the laparoscope, the entire peritoneal cavity must be systematically reviewed, in search of differential diagnoses and unidentified pathologies. We must use the diagnostic and therapeutic qualities of laparoscopy. Bile duct endocrine tumors tend to remain silent until advanced stages, making the prognosis usually unfavorable, especially when they are unresectable. Endocrine neoplasias of the gallbladder, although uncommon, should be taken into account as possible diagnoses due to its therapeutic and prognostic implications.

Aplicaciones de la ultrasonografía en el sistema nervioso central para Neuroanestesia y cuidado neurocrítico / Ultrasound applications in the central nervous system for neuroanaesthesia and neurocritical care

Ultrasonography performed by non-radiologist specialists is a tool that contributes to the diagnosis and monitoring of neurocritical patients. It is a non-invasive, low-cost, accurate and fast method that helps improve safety and timeliness in settings where prompt decision-making is imperative, such as in the operating room, critical care units or the emergency room. The objective is to conduct a narrative review, presenting ultrasound applications focused on the central nervous system that may be useful in neuroanaesthesia and neurocritical care. A search was performed of related terms on databases in the medical literature. Relevant papers where selected and reviewed to perform a non-systematic review focusing on the visualization of the midline and lateral ventricles, the measurement of the optic nerve sheath as a surrogate marker of intracranial hypertension, and the use of colour Doppler for visualizing the middle cerebral artery. It is expected that the use of ultrasound examination of the central nervous system will continue to evolve given its advantages, good correlation with studies considered as the gold standard, and the growing availability of the device. Advancements in this field are expected to improve timeliness and provide objective guidance for decision-making. We recognize the importance of developing skills in the use of this method of exploration in those services where it is required.

La ultrasonografía realizada por especialistas no radiólogos es una herramienta que contribuye al diagnóstico y monitoreo de los pacientes neurocríticos. Adicionalmente es económica, precisa, no invasiva y rápida, lo que mejora la seguridad y oportunidad en escenarios donde la toma inmediata de decisiones es imperativa tales como salas de cirugía, unidades de cuidado crítico o servicios de urgencias. El objetivo es realizar una revisión narrativa presentando las aplicaciones ultrasonográficas enfocadas al sistema nervioso central (SNC) que pueden ser útiles en neuroanestesia y cuidado neurocrítico. Se realizó una búsqueda en bases de datos de los términos relacionados en la literatura médica. Se seleccionaron y revisaron artículos de relevancia para realizar una revisión no sistemática que se centró en la visualización de la línea media, ventrículos laterales, medición de la vaina del nervio óptico como subrogador de hipertensión endocraneana y en la visualización de la arteria cerebral media a través de doppler color. Se prevé que continuarán los avances en la exploración ultrasonográfica del SNC debido a sus ventajas, la buena correlación con los estudios considerados como estándar de oro y la creciente disponibilidad de ecógrafo. Es de esperar que se mejore la oportunidad y ayude a dirigir la toma de decisiones objetivamente. Se reconoce la importancia del desarrollo de habilidades en el manejo de este método de exploración para aplicarlo en los servicios donde sea requerido.

Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies.

BACKGROUND: Emergency medicine (EM) is a growing specialty in Colombia with five residency programs in the country. EM leadership is interested in incorporating point-of-care (POC) ultrasound into a standardized national EM residency curriculum. This study is a nationwide survey of Colombian EM residents designed to explore the current state of POC ultrasound use within EM residencies and examine specific barriers preventing its expansion. METHODS: We conducted a mix-methodology study of all available current EM residents in the five EM residencies in Colombia. The quantitative survey assessed previous ultrasound experience, current use of various applications, desire for further training, and perceived barriers to expanded use. Focus group discussions (FGDs) were conducted with current EM residents to gather additional qualitative insight into their practice patterns and perceived barriers to clinician-performed ultrasound. RESULTS: Sixty-nine EM residents completed the quantitative survey, a response rate of 85% of all current EM residents in Colombia; 52% of resident respondents had previously used ultrasound during their training. Of these, 58% indicated that they had performed <10 scans and 17% reported >40 scans. The most frequently used applications indicated by respondents were trauma, obstetrics, and procedures including vascular access. A quarter indicated they had previously received some ultrasound training, but almost all expressed an interest in learning more. Significant barriers included lack of trained teachers (indicated by 78% of respondents), absence of machines (57%), and limited time (41%). In FGDs, the barriers identified were inter-specialty conflicts over the control of ultrasonography, both institutionally and nationally, and program-specific curriculum decisions to include POC ultrasound. CONCLUSION: While currently limited in their access, EM residents in Colombia have a strong interest in integrating POC ultrasound into their training. Current barriers to expanded use include traditional barriers such as a lack of equipment seen in many developing countries, as well as inter-specialty conflicts typical of developed countries. Further collaboration is underway to help overcome these obstacles and integrate POC ultrasound into Colombian EM residency training.

¿Es justificable para las instituciones de salud la inclusión de urgentólogos en los equipos de emergencias médicas? / Is it justifiable for the health institutions to include emergency physicians in the medical emergency teams?

Propósito: esta revisión pretende responder a la pregunta si se justifica incluir médicos especialistas en medicina de urgencias en los equipos de emergencias médicas (EEM). Materiales y Métodos: se realizó la búsqueda y selección de la literatura relevantes en Pubmed y Medline, usando los términos: “Medical Emergency Teams”, “Rapid Response Teams”, “Acute Teams”; combinándolos con “Emergency Medicine”, “Emergency Physicians” y “Emergency Departments” desde 1990 hasta el año 2009. Resultados: Actualmente es recomendada la conformación de los EEM como una medida en pro de la seguridad intrahospitalaria del paciente; sin embargo la literatura es conflictiva ya que algunos estudios sugieren que las intervenciones de estos equipos no disminuyen la frecuencia de presentación del paro cardiorrespiratorio, ni las admisiones a las unidades de cuidados intensivos. No es posible justificar la presencia de urgentólogos en estos equipos desde el punto de vista terapéutico, pues no existe literatura que compare los resultados de estos equipos en cuanto a los miembros que los conforman, aunque desde el punto de vista administrativo la presencia de urgentólogos en los EEM potencialmente impacta negativamente en la dinámica del servicio de urgencias. En vista de lo anterior no es recomendable incluir médicos especialistas de medicina de urgencias en los EEM.

Purpose of the review: This review aims at answering whether it is justified to include emergency physicians in the medical emergency teams (METs). Material and methods: The relevant literature was analyzed and selected in Pubmed and Medline, using the following terms: “Medical Emergency Teams”, “Rapid Response Teams”, “Acute Teams”, and combined with “Emergency Medicine”, “Emergency Physicians” and “Emergency Departments” from 1990 until 2009. Results: It is currently recommended to set up METs as a measure in favor of intra-hospital patient safety. Nevertheless, the literature shows some discrepancies because some studies suggest that the intervention of such teams do not reduce the frequency of heart and respiratory failure nor admissions to the intensive care units. Therefore, it cannot be recommended to include emergency physicians within those teams given that the economic overcost involved for health institutions in emergency services may not compensate for the results achieved by METs.

Obstetric and fetal outcomes in dystocic and eutocic sows to an injection of exogenous oxytocin during farrowing.

Sixty hybrid Yorkshire-Landrace penned sows, 30 with eutocic farrowing and 30 experiencing a dystocic parturition, were studied to evaluate the obstetric and neonatal outcomes to low doses of oxytocin administered at advanced stages of parturition. Animals in each group were randomly subdivided into 2 subgroups: 15 eutocic and 15 dystocic sows received oxytocin 0.083 IU/kg (equivalent to 1 IU/12 kg body weight), administered intramuscularly after the delivery of the 5th piglet; the other 15 eutocic and 15 dystocic sows received saline solution intramuscularly at the same time. Oxytocin decreased the number of intrapartum deaths by approximately 50% (P = 0.002). No piglet was born dead from the saline- and oxytocin-treated eutocic sows. The highest viability score was observed among piglets born to eutocic sows treated with oxytocin. In summary, this dose schedule would help to decrease the number of stillbirths in both eutocic and dystocic farrowing sows.

Effects of sildenafil on the fetal growth of guinea pigs and their ability to survive induced intrapartum asphyxia.

OBJECTIVE: Our goal was to determine whether sildenafil increased fetal weight and favored fetal tolerance to induced asphyxia at birth in guinea pigs. STUDY DESIGN: Twenty guinea pigs were randomly allocated to placebo (n = 10) or sildenafil 50 microg/kg (n = 5) or 500 microg/kg (n = 5), starting from day 35 of gestation to delivery. Fetuses were delivered by cesarean section. Fetal asphyxia was induced by clamping the umbilical cord at birth for 5 minutes. RESULTS: Sildenafil protected the pups against induced asphyxia at birth in a dose-dependent manner (eg, partial pressure (tension) of carbon dioxide levels were 75.9 +/- 19.3, 66.9 +/- 18.8, and 54.8 +/- 13.0 in the control and low- and high-dose sildenafil groups, respectively). The high-dose sildenafil group of piglets gained 1.5 times more body weight. CONCLUSION: In guinea pigs, low doses of sildenafil administered from day 35 to the end of gestation favored fetal tolerability to induced intrapartum asphyxia. High doses of sildenafil increased fetal weight.

Influence of time at which oxytocin is administered during labor on uterine activity and perinatal death in pigs.

Oxytocin is extensively used to induce or augment uterine contractions, especially to facilitate the third stage of labor in humans. Administration of oxytocin to parturient sows reduces duration of labor whereas mortality of the offspring may remain unchanged. This study aimed to evaluate whether time of administration of oxytocin during parturition may alter the uterine response and fetal outcomes. Two hundred parturient sows were randomly assigned to intramuscularly receive either saline solution (control group) or oxytocin 0.083 IU/kg immediately after the delivery of the 1st, 4th or 8th piglet (groups O-1, 0-4 and 0-8, respectively). Uterine effects and fetal outcomes were registered in all groups. The duration of labor was 20-40 min shorter (P < 0.0001) and time interval between babies was reduced by 3-5 min (P < 0.0001) in the three groups receiving oxytocin. The duration and intensity of contractions, meconium-stained piglets and intrapartum deaths decreased as time at which oxytocin administered during labor was increased. In group 0-8, we observed approximately 70% less meconium-stained piglets and intrapartum deaths than in the control group. In conclusion, oxytocin administered at early phases of parturition to sows may increase duration and intensity of uterine contractions as well as adverse fetal outcomes.

Influence of time at which oxytocin is administered during labor on uterine activity and perinatal death in pigs

Oxytocin is extensively used to induce or augment uterine contractions, especially to facilitate the third stage of labor in humans. Administration of oxytocin to parturient sows reduces duration of labor whereas mortality of the offspring may remain unchanged. This study aimed to evaluate whether time of administration of oxytocin during parturition may alter the uterine response and fetal outcomes. Two hundred parturient sows were randomly assigned to intramuscularly receive either saline solution (control group) or oxytocin 0.083 IU/kg immediately after the delivery of the 1st, 4th or 8th piglet (groups O-1, 0-4 and 0-8, respectively). Uterine effects and fetal outcomes were registered in all groups. The duration of labor was 20-40 min shorter (P < 0.0001) and time interval between babies was reduced by 3-5 min (P < 0.0001) in the three groups receiving oxytocin. The duration and intensity of contractions, meconium-stained piglets and intrapartum deaths decreased as time at which oxytocin administered during labor was increased. In group 0-8, we observed approximately 70 percent less meconium-stained piglets and intrapartum deaths than in the control group. In conclusion, oxytocin administered at early phases of parturition to sows may increase duration and intensity of uterine contractions as well as adverse fetal outcomes.

Individual and family household smoking habits as risk factors for wheezing among adolescents.

BACKGROUND: The study aimed to evaluate the household smoking habits as risk factors for wheezing in adolescents. METHODS: During a 2-month period, the study was performed by applying the standardized ISAAC phase 1 questionnaire to 3474 adolescents attending a random sample of secondary public schools located at the southeast of Mexico City. Adolescents were grouped as "cases" if they had at least one episode of wheezing in the year prior to the study, or as "controls" if they did not. Positive individual and family (father, mother or other persons living in the home) smoking habits at home were evaluated as potential risk factors. RESULTS: More than 98% of respondents in the two groups reported that the father smoked in the house. More mothers who smoked were reported among cases than controls (OR 2.42; 95% CI 1.60-3.68). More adolescents in the group of cases had history of ever having rhinitis, rash or wheezing. Fifty-four percent of adolescents in the group of cases had ever smoked versus 38.8% of controls (OR 1.89; 95% CI 1.33-2.67). Sex-adjusted logistic regression analysis identified a "protective" role for wheezing when the number of smokers at home was < or =2 (OR 0.44; 95% CI 0.27-0.71). CONCLUSION: Individual, maternal and other family members' indoor smoking habits may increase the risk of wheezing among adolescents.

Randomized trial comparing overnight preoperative fasting period Vs oral administration of apple juice at 06:00-06:30 am in pediatric orthopedic surgical patients.

BACKGROUND: We aimed to evaluate the efficacy of clear liquids orally administered at 06:00-06:30 am on the morning of surgery to reduce prolonged preoperative fasting periods. METHODS: After obtaining informed parental consent, 100 children undergoing scheduled orthopedic surgical procedures, ASA I-II, were randomly allocated to two groups. In group 1, children underwent the typical overnight preoperative period and patients in group 2 received a commercial brand of apple juice (glucose 28 g in 250 ml) at 06:00-06:30 am on the day of surgery. Patients <3 years old received 15 ml.kg(-1) and older children 10 ml.kg(-1) to a maximum volume of 250 ml. All patients underwent overnight fasting for milk and solids. RESULTS: Fasting time was 4.8 +/- 2.1 h (ranging from 3 to 11 h) in the group receiving apple juice at 06:00-06:30 am and 13.2 +/- 3.3 h (ranging from 5 to 19 h) in the overnight-fasting group (P < 0.05; 95% CI: -9.6 to -7.4 h). More patients were irritable (odds ratio, OR 4.5; 95% CI: 1.9-10.8) and dehydrated (OR 21.6; 95% CI: 5.9-79.0) in the overnight-fasting group. Glucose levels <2.7 mmol.l(-1) (50 mg.dl(-1)) were not reported in any case. CONCLUSIONS: A 15 ml.kg(-1) of apple juice for patients of <3 years of age or 10 ml.kg(-1) for older children, at 06:00-06:30 am of the surgical morning is a simple procedure to prevent dehydration and to produce positive behavior in low-risk, pediatric surgical patients.

Dose minimization study of oxytocin in early labor in sows: uterine activity and fetal outcome.

Two hundred sows were randomly assigned to intramuscularly receive 0.9% NaCl (group 1) or oxytocin 0.083, 0.11 or 0.17 IU/kg (groups 2, 3 and 4, respectively) immediately after the expulsion of the first piglet. The overall duration of labor was decreased in a dose-dependent relationship. Time interval between piglets was decreased approximately 5 min in groups 3 and 4 while sows in these groups exhibited approximately 10-20 contractions x 10 births more than controls (P<0.005). Duration and intensity of uterine contractions also showed a positive dose-response relationship. As an indicative of fetal distress, approximately 2.5 times more meconium-stained piglets were born to sows receiving the higher doses of oxytocin, but in the lowest dose significantly decreased. Oxytocin 0.083 IU/kg significant decreased the mortality rate of piglets [OR 0.49 (95%CI, 0.26-0.92)]. In conclusion, we recommend the intramuscular administration of the lowest possible dose of oxytocin, which still decreases the duration of labor in sows.

Dose-response of ropivacaine administered caudally to children undergoing surgical procedures under sedation with midazolam.

1. In a double-blind randomized controlled design, 50 children were allocated to receive bupivacaine 0.25% or ropivacaine 0.25%, 0.32%, 0.40% or 0.50% by caudal block. 2. Caudal block was performed after induction of anaesthesia with 2-5% sevoflurane, atropine 10 microg/kg and midazolam 100-300 microg/kg. During the surgical procedure, patients were maintained under spontaneous ventilation and no intravenous or inhalatory anaesthetic agent was administered. For transoperative sedation, midazolam 100-300 microg/kg was administered every 0.5-1.0 h. Transoperative cardiovascular response, postoperative analgesia and local and systemic complications were evaluated. 3. Groups were similar (P > 0.05) in sex, age, weight and in the time elapsed from caudal block to the beginning of the surgical procedure. The surgical time was significantly lower in the ropivacaine 0.25% group. The duration of analgesia was 24 h with ropivacaine 0.25% and approximately 10 h in the other four groups (P < 0.001). Linear regression analysis revealed a significant relationship between the postoperative analgesic period produced by ropivacaine and the surgical time (r = -0.48, two-sided P = 0.002). Systolic and diastolic blood pressures remained in the physiologically normal range for the duration of the transoperative period. Vomiting was present in only one patient receiving ropivacaine 0.50%. 4. In children, the duration of analgesia produced by caudal block with ropivacaine may be affected by surgical time. At surgical times of 0.5-1 h, ropivacaine 0.25% produced at least 24 h postoperative analgesia. At similar surgical times, ropivacaine 0.32%, 0.40% and 0.50% produced similar analgesic times to bupivacaine 0.25%.

Sexually transmitted infections associated with vulvovaginal symptoms in adolescents denying sexual activity.

OBJECTIVE: To identify clinical, laboratory and ultrasonographic evidence of a probable sexually transmitted infection associated with vulvovaginal symptoms in adolescents denying sexual activity. MATERIAL AND METHODS: The medical records of female adolescents, aged 10-18 years were reviewed. These women received first-time medical care for vulvovaginitis, between 1995 and 1999 at Hospital Infantil de México Federico Gómez, (Children's Hospital). Comparisons between groups were performed, as appropriate, by the unpaired Student's t-test, the Z test or the chi-square test; statistically significant differences were set at a two-tailed p < 0.05. Odds ratios with 95% confidence intervals were calculated. RESULTS: Of 258 adolescents with vulvovaginitis, 53 (20.5%) had a sexually transmitted microorganism and 52 of them denied ever having sexual activity. Age, education and socioeconomic level, development of sexual characters, and presence of menstruation did not differ between patients with and without sexually transmitted infections. The presence of sexually transmitted infections was associated with lower abdominal pain, abnormally colored vaginal discharge, a positive urine culture, and an abdominal ultrasonographic evidence, compatible with pelvic inflammatory disease (ultrasonographic odds ratio 144.8; 95% CI 51.0 to 411.3). CONCLUSIONS: There is an association between sexually transmitted infections in young women with vulvovaginitis and lower abdominal pain, abnormally colored vaginal discharge, a positive urine culture, and an abdominal ultrasonographic evidence compatible with pelvic inflammatory disease. The English version of this paper is available too at:http://www.insp.mx/salud/index.html.

Sexually transmitted infections associated with vulvovaginal symptoms in adolescents denying sexual activity

OBJETIVO: Identificar datos clínicos, de laboratorio y ultrasonográficos que permitan el diagnóstico de una infección de transmisión sexual asociada a síntomas vulvovaginales en las pacientes adolescentes que niegan vida sexual activa. MATERIAL Y MÉTODOS: Se revisaron los expedientes de las adolescentes de 10 a 18 años de edad que requirieron atención médica de primera vez por vulvovaginitis entre 1995 y 1999 en el Hospital Infantil de México Federico Gómez. Las comparaciones entre grupos se llevaron a cabo con la prueba t de Student, la prueba de Z, o la de ji-cuadrada. Se utilizó un valor de p<0.05 para establecer diferencias estadísticamente significativas. Se calcularon razones de momios con intervalos de confianza de 95%. RESULTADOS: De 258 adolescentes, en 53 (20.5%) se identificó un microrganismo de transmisión sexual y 52 de ellas negaron tener vida sexual activa. No hubo diferencias estadísticas entre los dos grupos de adolescentes en cuanto a la edad, los años de estudio, el nivel socioeconómico, la maduración sexual y la presencia de menarquia. El dolor abdominal en los cuadrantes inferiores, la coloración anormal de la secreción vaginal, un cultivo urinario positivo y un estudio ultrasonográfico abdominal compatible con enfermedad pélvica inflamatoria estuvieron asociados con infección de transmisión sexual. Con el estudio ultrasonográfico se obtuvo una razón de momios de 144.8 (intervalo de confianza 95% 51.0 a 411.3). CONCLUSIONES: Se demostró una asociación entre infección de transmisión sexual en adolescentes con vulvovaginitis y dolor abdominal bajo, secreción vaginal anormal, urocultivo positivo y un estudio ultrasonográfico compatible con enfermedad pélvica inflamatoria.