Complicaciones a corto y medio plazo en pacientes con fibrilación auricular que acuden a urgencias: diseño y validación interna de la escala CoSTuM / Short- and medium-term complications after emergency department treatment of patients with atrial fibrillation: design and internal validation of the CoSTuM risk scale

Objetivo. Diseñar y validar una escala clínica para predecir el riesgo de sufrir eventos adversos a los 90 días del alta de urgencias en pacientes con fibrilación auricular (FA).Método. Estudio observacional, prospectivo que incluyó pacientes con FA que acudieron a urgencias. Durante el seguimiento, se registró la incidencia de cualquier evento adverso. Se llevó a cabo un análisis de regresión logística multivariante para investigar las variables independientemente asociadas con eventos adversos. El 66% de los pacientes (seleccionados al azar) conformaron la cohorte de derivación y los restantes la cohorte de validación interna.Resultados. Se incluyeron 645 pacientes (50,2% mujeres, mediana de edad de 76 años, RIC 67-81) y 165 (25,6%) presentaron al menos un evento adverso (114 en la cohorte de derivación y 51 en la de validación interna). La edad $ 70 años, enfermedad vascular, insuficiencia cardiaca, enfermedad pulmonar obstructiva crónica (EPOC), enfermedad renal, obesidad, síntomas mal controlados (EHRA III-IV), uso de oxigenoterapia, digoxina y otros antiarrítmicos en urgencias y el mal control de la frecuencia cardiaca se asociaron independientemente con el riesgo de eventos adversos. Con estas variables se diseñó la escala CoSTuM (COmorbilidades, Sintomatología, Tratamiento en Urgencias y Mal control de la frecuencia cardiaca), que mostró una óptima capacidad predictiva tanto en la cohorte de derivación (estadístico c: 0,901, IC 95% 0,869-0,928; p < 0,001) como en la de validación (estadístico c: 0,850, IC 95% 0,796-0,894; p < 0,001).Conclusiones. En pacientes con FA atendidos en urgencias, la escala CoSTuM demostró tener una buena capacidad de predicción de eventos adversos a los 90 días tras el alta. (AU)

Objective. To design and validate a clinical risk scale for 90-day adverse events after emergency department (ED) discharge of patients with atrial fibrillation (AF).Methods. Prospective, observational CoSTuM (Spanish acronym for comorbidity, symptoms, treatments, and poor heart rate control) study of patients with AF. We recorded all adverse events occurring during follow-up and used multivariate logistic regression analysis to identify variables independently associated with the occurrence of any such event. A risk model was developed with data from a random sample of 66% of the patients. Data for the remaining patients were used for internal validation of the model.Results. We analyzed data for 645 patients (50.2% women; median [interquartile range] age, 76 (67–81 years). At 90 days, at least 1 adverse event had occurred in 165 patients (25.6%); 114 were in the development sample and 51 were in the validation sample. Independent variables associated with risk for adverse events were age 70 years or older; vascular disease; heart failure; chronic obstructive pulmonary disease; kidney disease; obesity; poorly controlled AF symptoms (European Heart Rhythm Association score, III–IV); use of oxygen therapy, digoxin, or other antiarrhythmics in the ED; and poor control of heart rate. The CoSTuM scale based on these variables demonstrated optimal predictive value in both the development sample (c statistic, 0.901; 95% CI, 0.869–0.928; P < .001) and the validation sample (c statistic, 0.850, 95% CI, 0.796–0.894; P < .001).Conclusion. The CoSTuM risk score was a good predictor of 90-day adverse events after ED discharge of patients treated for AF. (AU)

Short- and medium-term complications after emergency department treatment of patients with atrial fibrillation: design and internal validation of the CoSTuM risk scale. / Complicaciones a corto y medio plazo en pacientes con fibrilación auricular que acuden a urgencias: diseño y validación interna de la escala CoSTuM.

OBJECTIVES: To design and validate a clinical risk scale for 90-day adverse events after emergency department (ED) discharge of patients with atrial fibrillation (AF). MATERIAL AND METHODS: Prospective, observational CoSTuM (Spanish acronym for comorbidity, symptoms, treatments, and poor heart rate control) study of patients with AF. We recorded all adverse events occurring during follow-up and used multivariate logistic regression analysis to identify variables independently associated with the occurrence of any such event. A risk model was developed with data from a random sample of 66% of the patients. Data for the remaining patients were used for internal validation of the model. RESULTS: We analyzed data for 645 patients (50.2% women; median [interquartile range] age, 76 (67-81 years). At 90 days, at least 1 adverse event had occurred in 165 patients (25.6%); 114 were in the development sample and 51 were in the validation sample. Independent variables associated with risk for adverse events were age 70 years or older; vascular disease; heart failure; chronic obstructive pulmonary disease; kidney disease; obesity; poorly controlled AF symptoms (European Heart Rhythm Association score, III-IV); use of oxygen therapy, digoxin, or other antiarrhythmics in the ED; and poor control of heart rate. The CoSTuM scale based on these variables demonstrated optimal predictive value in both the development sample (c statistic, 0.901; 95% CI, 0.869-0.928; P .001) and the validation sample (c statistic, 0.850, 95% CI, 0.796-0.894; P .001). CONCLUSION: The CoSTuM risk score was a good predictor of 90-day adverse events after ED discharge of patients treated for AF.

OBJETIVO: Diseñar y validar una escala clínica para predecir el riesgo de sufrir eventos adversos a los 90 días del alta de urgencias en pacientes con fibrilación auricular (FA). METODO: Estudio observacional, prospectivo que incluyó pacientes con FA que acudieron a urgencias. Durante el seguimiento, se registró la incidencia de cualquier evento adverso. Se llevó a cabo un análisis de regresión logística multivariante para investigar las variables independientemente asociadas con eventos adversos. El 66% de los pacientes (seleccionados al azar) conformaron la cohorte de derivación y los restantes la cohorte de validación interna. RESULTADOS: Se incluyeron 645 pacientes (50,2% mujeres, mediana de edad de 76 años, RIC 67-81) y 165 (25,6%) presentaron al menos un evento adverso (114 en la cohorte de derivación y 51 en la de validación interna). La edad 70 años, enfermedad vascular, insuficiencia cardiaca, enfermedad pulmonar obstructiva crónica (EPOC), enfermedad renal, obesidad, síntomas mal controlados (EHRA III-IV), uso de oxigenoterapia, digoxina y otros antiarrítmicos en urgencias y el mal control de la frecuencia cardiaca se asociaron independientemente con el riesgo de eventos adversos. Con estas variables se diseñó la escala CoSTuM (COmorbilidades, Sintomatología, Tratamiento en Urgencias y Mal control de la frecuencia cardiaca), que mostró una óptima capacidad predictiva tanto en la cohorte de derivación (estadístico c: 0,901, IC 95% 0,869-0,928; p 0,001) como en la de validación (estadístico c: 0,850, IC 95% 0,796-0,894; p 0,001). CONCLUSIONES: En pacientes con FA atendidos en urgencias, la escala CoSTuM demostró tener una buena capacidad de predicción de eventos adversos a los 90 días tras el alta.

Cardiac tamponade and right ventricle perforation after an acupuncture procedure / Taponamiento cardíaco y perforación del ventrículo derecho después de un procedimiento de acupuntura

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A Sustainable Approach to the Metabolic Syndrome in Children and Its Economic Burden.

The prevalence of obesity continues to grow, resulting in metabolic syndrome and increasing economic burden for health systems. The objectives were to measure the ability of the NIM-MetS test, previously used in the adults, for the early and sustainable detection of the Metabolic Syndrome (MetS) in children and adolescents. Moreover, to determine the economic burden of the children with MetS. Furthermore, finally, to use and implement the NIM-MetS test, via a self-created online software, as a new method to determine the risk of MetS in children. The method used was an observational study using different instruments (NIM-MetS test, International Diabetes Federation (IDF), or Cook) and measures (body mass index). Additionally, the economic burden was estimated via a research strategy in different databases, e.g., PubMed, to identify previous papers. The results (N = 265 children, age from 10-12) showed that 23.1% had obesity and 7.2% hypertension. The prevalence of MetS using the NIM-Mets was 5.7, and the cost of these children was approximate 618,253,99 euros. Finally, a model was obtained and later implemented in a web platform via simulation. The NIM-MetS obtained is a non-invasive method for the diagnosis of risk of MetS in children.

Abdominal Pain in a Young Female Adolescent: Point-of-Care Ultrasound Added Value.

An adolescent female patient presented to the emergency department with diffuse, severe lower abdominal pain and vomiting. The initial suspected diagnosis was appendicitis. Point-of-care ultrasound did not visualize the appendix but demonstrated a suspected left ovarian torsion, which was confirmed by radiology-performed ultrasound. The clinical presentation, in combination with images obtained via point-of-care ultrasound, helped to expedite gynecology consultation and immediate surgery.

Estudio de la obesidad en una población infantil rural y su relación con variables antropométricas / Study of obesity in a rural children population and its relationship with anthropometric variables

Objetivos: Conocer la prevalencia de obesidad en escolares de educación primaria y secundaria, y evaluar la precisión diagnóstica de variables antropométricas para su detección. Diseño: Estudio transversal. Año 2014. Emplazamiento: Área rural de Córdoba. Participantes: Población estudiantil. Se llevó a cabo un muestreo estratificado por edad, género y centros educativos. Un total de 323 alumnos de 6 a 16 años fueron estudiados, cuyos padres habían firmado el consentimiento informado. Mediciones principales: Se determinó la prevalencia de obesidad y se recogieron variables predictoras sociodemográficas, antropométricas, de condición física y alimentación. Se realizó una regresión logística binaria determinando los valores de odds ratio (OR) crudas y ajustadas, se confeccionaron curvas ROC y se determinaron valores de corte, calculando la sensibilidad, la especificidad y el índice de Youden. Resultados: La prevalencia de sobrepeso y obesidad fue del 26,2 y 22,3%, respectivamente. Solo un 15,2% de los escolares realizó dieta mediterránea óptima. El índice cintura-altura (ICT) fue la variable predictiva con mayor OR ajustada (7,1 [4,3-11,6]) y mayor área bajo la curva (0,954 [0,928-0,979]); a partir de un valor de corte global para discriminar obesidad de 0,507, consiguió una sensibilidad del 90% y una especificidad del 87,2%. Conclusiones: La alta prevalencia de obesidad, la media-baja adherencia a la dieta mediterránea y la baja condición física hacen de esta población un objetivo prioritario de actuación para la prevención de futuros eventos cardiovasculares. El ICT ha sido el mejor predictor antropométrico de obesidad, recomendándose su uso para el diagnóstico de obesidad en población infantil en detrimento del índice de masa corporal

Goals: To know the prevalence of obesity in primary and secondary school students, and to evaluate the diagnostic accuracy of anthropometric variables for its detection. Design: Cross-sectional study. Location: Rural area of Córdoba. In the year 2014. Participants: Student population. A stratified sampling was performed according to age, gender and educational centers. A total of 323 students from 6 to 16 years were included in the study, all parents had signed informed consent. Main measurements: The prevalence of obesity was determined and sociodemographic, anthropometric, physical condition and dietary predictor variables were collected. A binary logistic regression was performed determining crude and adjusted Odds Ratio (OR) values, ROC curves were obtained and cut-off values were determined, calculating the sensitivity, specificity and Youden index. Results: The prevalence of overweight and obesity was 26.2% and 22.3%, respectively. Only 15.2% of school children had an optimal Mediterranean diet. The waist-height ratio (WtHR) was the predictive variable with the highest adjusted OR 7.1 (4.3-11.6) and the largest area under the curve 0.954 (0.928-0.979), from a global cut-off value to discriminate obesity of 0.507. This gave a sensitivity of 90% and specificity of 87.2%. Conclusions: The high prevalence of obesity, the low-medium adherence to the Mediterranean diet and the low physical fitness make this population a priority target for the prevention of future cardiovascular events. The WtHR has been the best anthropometric predictor of obesity, recommending its use for the diagnosis of obesity in children at the expense of body mass index

Abdomen agudo secundario a torsión de bazo ectópico como causa inusual de dolor abdominal en urgencias / Acute Abdomen After Ectopic Spleen Torsion as an Unusual Cause of Abdominal Pain in the Emergency Department

RESUMEN El bazo ectópico es una enfermedad infrecuente, que se caracteriza por el aumento de la movilidad del bazo debido a la ausencia o laxitud de sus ligamentos suspensorios, lo que puede dar lugar a una torsión de su pedículo, y provocar un abdomen agudo. Se presenta el caso de una mujer de 29 años que acude al servicio de urgencias por presentar dolor abdominal de 7 meses de evolución, localizado en fosa ilíaca izquierda, que ha empeorado en las últimas 48 horas. Se realizó ecografía en el servicio de urgencias (point-of-care) que mostró una imagen compatible con bazo ectópico junto a su hilio, localizado en tercio inferior del abdomen cerca de la vejiga y del útero, y líquido libre. La tomografía axial computarizada confirmó el diagnóstico de torsión del pedículo. Se realizó laparotomía de urgencia y se localizó el bazo dentro de la pelvis con torsión del pedículo; ante un bazo no viable se realizó esplenectomía. La histología demostró cambios trombóticos difusos con infartos isquémicos y hemorrágicos del bazo. A pesar de su baja prevalencia, el bazo ectópico se debe tener en cuenta a la hora de realizar el diagnóstico diferencial en aquellas mujeres en edad fértil que consultan por dolor abdominal o masa pélvica(AU)

ABSTRACT Ectopic spleen is a rare disease, characterized by increased mobility of the spleen due to the absence or laxity of its suspensory ligaments, which can lead to torsion of its pedicle and cause acute abdomen. We present the case of a 29-year-old woman who attends the emergency department with abdominal pain of seven months of evolution and located in the left iliac fossa, which has worsened in the last 48 hours. An ultrasound was performed in the emergency department (point-of-care), which showed, next to its hilum, an image consistent with ectopic spleen, located in the lower third of the abdomen near the bladder and uterus, and free fluid. Computed axial tomography confirmed the diagnosis of pedicle torsion. Emergency laparotomy was performed and the spleen was located inside the pelvis with torsion of the pedicle. Splenectomy was performed before a non-viable spleen. Histology showed diffuse thrombotic changes with ischemic and hemorrhagic infarcts of the spleen. Despite its low prevalence, the ectopic spleen should be taken into account when making the differential diagnosis in those women at childbearing age who come to the clinic for abdominal pain or pelvic mass(AU)

[Study of obesity in a rural children population and its relationship with anthropometric variables]. / Estudio de la obesidad en una población infantil rural y su relación con variables antropométricas.

GOALS: To know the prevalence of obesity in primary and secondary school students, and to evaluate the diagnostic accuracy of anthropometric variables for its detection. DESIGN: Cross-sectional study. LOCATION: Rural area of Córdoba. In the year 2014. PARTICIPANTS: Student population. A stratified sampling was performed according to age, gender and educational centers. A total of 323 students from 6 to 16 years were included in the study, all parents had signed informed consent. MAIN MEASUREMENTS: The prevalence of obesity was determined and sociodemographic, anthropometric, physical condition and dietary predictor variables were collected. A binary logistic regression was performed determining crude and adjusted Odds Ratio (OR) values, ROC curves were obtained and cut-off values were determined, calculating the sensitivity, specificity and Youden index. RESULTS: The prevalence of overweight and obesity was 26.2% and 22.3%, respectively. Only 15.2% of school children had an optimal Mediterranean diet. The waist-height ratio (WtHR) was the predictive variable with the highest adjusted OR 7.1 (4.3-11.6) and the largest area under the curve 0.954 (0.928-0.979), from a global cut-off value to discriminate obesity of 0.507. This gave a sensitivity of 90% and specificity of 87.2%. CONCLUSIONS: The high prevalence of obesity, the low-medium adherence to the Mediterranean diet and the low physical fitness make this population a priority target for the prevention of future cardiovascular events. The WtHR has been the best anthropometric predictor of obesity, recommending its use for the diagnosis of obesity in children at the expense of body mass index.

Sudden headache, lumbar puncture, and the diagnosis of subarachnoid hemorrhage in patients with a normal computed tomography scans. / Cefalea súbita, punción lumbar y diagnóstico de hemorragia subaracnoidea en pacientes con una tomografía computarizada normal.

OBJECTIVES: To assess the usefulness of computed tomography (CT) to identify subarachnoid bleeding in patients with neurologic deficits seeking emergency care for sudden headache within 6 hours of onset of symptoms. MATERIAL AND METHODS: Retrospective observational study of patients presenting with sudden nontraumatic headache peaking during the previous hour in the absence of neurologic deficits. We ordered CT scans for all patients, and if the scan was normal we performed a lumbar puncture. All patients were then followed for 6 months. RESULTS: Eighty-five patients were included. Subarachnoid bleeding was identified in 10 (10.2%) patients by CT. Seventy- four lumbar punctures were performed in patients with negative CTs; the lumbar puncture was positive in 1 patient and inconclusive in 2 patients. In all 3 patients, bleeding was ruled out with later images; thus, no cases of subarachnoid hemorrhage were confirmed in the 74 patients who underwent lumbar puncture. Nor were any cases found in any of these patients during follow-up. CONCLUSION: A CT scan taken within 6 hours of onset of sudden headache is sufficient for confirming or ruling out subarachnoid bleeding in patients with sudden headache who have no neurologic deficits.

OBJETIVO: Valorar la utilidad de la tomografía computarizada (TC) para identificar la hemorragia subaracnoidea (HSA) en pacientes que consultan en el servicio de urgencias por cefalea súbita sin déficit neurológico dentro de las seis primeras horas desde el comienzo de los síntomas. METODO: Estudio observacional, retrospectivo, de pacientes que consultaron por cefalea súbita, no traumática, con un pico de máxima intensidad dentro de la hora previa y sin déficit neurológico. A todos los pacientes se les realizó una TC seguida de una punción lumbar (PL) si la TC era normal, y seguimiento a los 6 meses. RESULTADOS: Se incluyeron 85 pacientes. Se diagnosticaron 10 (10,2%) casos de HSA en la TC, y se realizaron 74 PL, en pacientes con una TC negativa, de las que una fue positiva y dos no concluyentes, pero en estudios posteriores de imagen se descartó la HSA. En total, la PL en 74 pacientes con TC normal no confirmó ningún caso de HSA. Tampoco se confirmó ningún caso durante el seguimiento. CONCLUSIONES: En los pacientes con cefalea súbita y sospecha de HSA, sin inconsciencia ni focalidad neurológica, una TC de alta resolución realizada en las primeras 6 horas desde la aparición de la cefalea fue suficiente para confirmar o descartar ese diagnóstico.

Cefalea súbita, punción lumbar y diagnóstico de hemorragia subaracnoidea en pacientes con una tomografía computarizada normal / Sudden headache, lumbar puncture, and the diagnosis of subarachnoid hemorrhage in patients with a normal computed tomography scans

Objetivo. Valorar la utilidad de la tomografía computarizada (TC) para identificar la hemorragia subaracnoidea (HSA) en pacientes que consultan en el servicio de urgencias por cefalea súbita sin déficit neurológico dentro de las seis primeras horas desde el comienzo de los síntomas. Método. Estudio observacional, retrospectivo, de pacientes que consultaron por cefalea súbita, no traumática, con un pico de máxima intensidad dentro de la hora previa y sin déficit neurológico. A todos los pacientes se les realizó una TC seguida de una punción lumbar (PL) si la TC era normal, y seguimiento a los 6 meses. Resultados. Se incluyeron 85 pacientes. Se diagnosticaron 10 (10,2%) casos de HSA en la TC, y se realizaron 74 PL, en pacientes con una TC negativa, de las que una fue positiva y dos no concluyentes, pero en estudios posteriores de imagen se descartó la HSA. En total, la PL en 74 pacientes con TC normal no confirmó ningún caso de HSA. Tampoco se confirmó ningún caso durante el seguimiento. Conclusiones. En los pacientes con cefalea súbita y sospecha de HSA, sin inconsciencia ni focalidad neurológica, una TC de alta resolución realizada en las primeras 6 horas desde la aparición de la cefalea fue suficiente para confirmar o descartar ese diagnóstico (AU)

Objective. To assess the usefulness of computed tomography (CT) to identify subarachnoid bleeding in patients with neurologic deficits seeking emergency care for sudden headache within 6 hours of onset of symptoms. Methods. Retrospective observational study of patients presenting with sudden nontraumatic headache peaking during the previous hour in the absence of neurologic deficits. We ordered CT scans for all patients, and if the scan was normal we performed a lumbar puncture. All patients were then followed for 6 months. Results. Eighty-five patients were included. Subarachnoid bleeding was identified in 10 (10.2%) patients by CT. Seventy-four lumbar punctures were performed in patients with negative CTs; the lumbar puncture was positive in 1 patient and inconclusive in 2 patients. In all 3 patients, bleeding was ruled out with later images; thus, no cases of subarachnoid hemorrhage were confirmed in the 74 patients who underwent lumbar puncture. Nor were any cases found in any of these patients during follow-up. Conclusions. A CT scan taken within 6 hours of onset of sudden headache is sufficient for confirming or ruling out subarachnoid bleeding in patients with sudden headache who have no neurologic déficits (AU)

Catastrophic antiphospholipid antibody syndrome presenting as acute vascular occlusion in a young female patient / Síndrome de anticuerpos antifosfolípidos catastrófico que se presenta con oclusión vascular aguda en una paciente joven

Acquired thrombotic and thromboembolic disorders may be presented initially with symptoms and signs of acute ischaemia or organ dysfunction that will lead many of these patients to seek care in the emergency department. We report a case of a 19-year-old female patient who developed catastrophic antiphospholipid syndrome (CAPS syndrome or Asherson syndrome) 6 weeks post stillbirth with an initial presentation of acute vascular occlusion. The patient was immediately operated and anticoagulated with significant improvement (AU)

Los trastornos trombóticos y tromboembólicos adquiridos pueden manifestarse inicialmente con signos y síntomas de isquemia aguda o disfunción orgánica que derivará a muchos de estos pacientes al servicio de urgencias. Se presenta el caso de una paciente de 19 años de edad que desarrolló un síndrome antifosfolípido catastrófico (o síndrome de Asherson) 6 semanas después del parto de un feto muerto con una presentación inicial de oclusión vascular aguda. La paciente fue intervenida inmediatamente y se inició un tratamiento con anticoagulantes que supuso una mejora significativa (AU)

Comparison of the Accuracy of Emergency Department-Performed Point-of-Care-Ultrasound (POCUS) in the Diagnosis of Lower-Extremity Deep Vein Thrombosis.

BACKGROUND: Compression ultrasonography is the most effective diagnostic tool in the emergency department (ED) for the diagnosis of deep vein thrombosis (DVT). It has been demonstrated to be highly accurate and cost-effective. OBJECTIVE: The objective of this study was to determine the accuracy of emergency physicians who performed three-point compression ultrasound (US) for suspected above-knee DVT within the context of using Wells score and D-dimer. METHOD: This was a prospective diagnostic test assessment of three-point ultrasound conducted in a district general hospital of patients who presented to the ED with suspected DVT of the lower limb. The accuracy of three-point ultrasound carried out by the emergency physicians was assessed by comparison of the Doppler ultrasound carried out by the Radiology Department as reference standard. The study incorporated ultrasound alongside the Wells score and D-dimer. RESULTS: A total of 109 patients (66.1%) had a three-point compression point-of-care ultrasound in the ED and a second ultrasound performed by the Radiology Department. Bedside three-point compression ultrasound of the lower extremity performed by physicians in the ED had a sensitivity of 93.2% (95% confidence interval [CI] 83.8-97.3%) and a specificity of 90.0% (95% CI 78.6-95.7%), with an accuracy of 91.7% (95% CI 85-95.6%). CONCLUSIONS: Emergency physicians can obtain a level of competence equivalent to that of radiologists, but it requires substantial training and practice to achieve and maintain this performance. Providers should be aware of their limitations and maintain regular training with ultrasound applications.