Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study.

OBJECTIVES: Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache. METHODS: Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination. RESULTS: 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%). CONCLUSION: The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning. TRIAL REGISTRATION NUMBER: ANZCTR376695.

Epidemiology of headache in a neurological Emergency Department in Medellin, Colombia / Epidemiology of headache in a neurological Emergency Department in Medellin, Colombia

Introduction:Headache is a common reason for presentation to emergency departments (ED) around the world. In many countries, ED are not speciality-focussed, however, in Colombia and some other countries, specialist neurological hospitals have ED with a strong neurological focus. For patients presenting with headache, these ED may have different epidemiology, investigation strategies and treatment patterns from general ED. Objective:The objective of this study was to describe the epidemiology of headache presenting to the ED of Instituto Neurológico de Colombia in Medellin, Colombia ­ an ED which is a referral centre for neurological and neurosurgical diseases. Methods:This was an observational study by chart review of adults (aged ≥18) with a main presenting compliant of headache. Demographic, clinical, imaging, diagnoses and outcome data were collected. The primary outcome of interest was the rate of serious secondary intracranial headache cause. Analysis was descriptive. Results:757 patients were studied ­ female 76%, median age 39. Most headache were of gradual onset (85%) and new neurological signs were uncommon (4%). CT was performed in 50% of cases and MRI in 20%. A wide variety of headache causes were identified. Serious secondary intracranial headache was identified in 8.9% (95% CI 7.1-11.1%) of cases. Most patients (89%) were discharged home from ED. Conclusion:Diagnosis of headache in ED is challenging with a very wide range of possible causes. A small proportion of patients (approx. 9%) have a serious cause for their symptoms ­ a proportion similar to that reported in other international emergency department cohorts.

Introdução: A cefaleia é um motivo comum de apresentação aos departamentos de emergência (DE) em todo o mundo. Em muitos países, os PS não são focados em especialidades, no entanto, na Colômbia e em alguns outros países, os hospitais neurológicos especializados têm PS com um forte foco neurológico. Para pacientes que apresentam cefaleia, esses DE podem ter epidemiologia, estratégias de investigação e padrões de tratamento diferentes dos DE geral. Objetivo: O objetivo deste estudo foi descrever a epidemiologia da dor de cabeça apresentada ao pronto-socorro do Instituto Neurológico de Colômbia em Medellín, Colômbia ­ um pronto-socorro que é um centro de referência para doenças neurológicas e neurocirúrgicas. Métodos: Este foi um estudo observacional por meio de revisão de prontuários de adultos (idade ≥18) com apresentação principal complacente de cefaleia. Dados demográficos, clínicos, de imagem, diagnósticos e resultados foram coletados. O desfecho primário de interesse foi a taxa de causa grave de dor de cabeça intracraniana secundária. A análise foi descritiva. Resultados: Foram estudados 757 pacientes ­ 76% do sexo feminino, idade mediana de 39 anos. A maioria das cefaleias foi de início gradual (85%) e os novos sinais neurológicos foram incomuns (4%). A tomografia computadorizada foi realizada em 50% dos casos e a ressonância magnética em 20%. Uma grande variedade de causas de dor de cabeça foi identificada. Cefaleia intracraniana secundária grave foi identificada em 8,9% (IC 95% 7,1-11,1%) dos casos. A maioria dos pacientes (89%) recebeu alta do pronto-socorro. Conclusão: O diagnóstico de cefaleia no DE é desafiador, com uma ampla gama de causas possíveis. Uma pequena proporção de pacientes (aproximadamente 9%) tem uma causa grave para os seus sintomas ­ uma proporção semelhante à relatada em outras coortes internacionais de serviços de emergência.

Effect of glutathione during bottle storage of sparkling wine.

Reduced glutathione (GSH) is an efficient antioxidant on limiting browning, losing varietal aromas and off-flavor formation. Therefore, this study aims to evaluate the effect of GSH addition (10, 20 and 30mgL(-1)) after the disgorging of the sparkling wine during storage. The sparkling wines were analyzed at 1, 6, 12 and 18months of storage according to the color index, concentration of the free SO2, phenolic compounds, catechin, epicatechin, caffeic acid, coumaric acid, acetaldehyde, total and reduced glutathione. The results show that GSH concentration decreased to the level of the control sparkling wine during the first 6months, and the total glutathione gradually declined up to 12months. The GSH reduces browning and acetaldehyde formation for up to 12months. However, the presence of glutathione had low or no influence on the concentration of free SO2, total phenolics, catechin, epicatechin, caffeic and coumaric acids.

Estado nutricional de pacientes en dos centros hospitalarios de villavicencio, colombia, 2015

Objetivo. Establecer el estado nutricional en pacientes de dos instituciones hospitalarias de Villavicencio. Método. Estudio de corte transversal, prospectivo, mediante una encuesta en 2 instituciones hospitalarias de Villavicencio, Colombia, en febrero de 2015. Se incluyeron pacientes adultos hospitalizados en servicios quirúrgicos. Los datos fueron registrados en Excel y se realizaron análisis estadísticos con SPSS a fin de encontrar asociaciones entre las variables de estudio y los desenlaces. El nivel de significancia se estableció cuando la p<0,05 mediante la prueba de Chi cuadrado y la t de Student. Resultados. Se entrevistaron 116 pacientes. El 56% de los pacientes fueron del hospital público, 58,8% fueron de servicios quirúrgicos y 65% fueron hombres. La edad promedio fue 65,7 (± 20,6) años. Solo 37,1% de los pacientes tenía el peso registrado en la historia clínica, por lo cual solo se pudo determinar el estado nutricional al 31% de los encuestados. Solo se pudo determinar un 23,1% de malnutrición, entre los cuales había un 9,5% de bajo peso. Los pacientes con mayor estancia hospitalaria fueron los del hospital público, en condición de desnutrición, sobrepeso y obesidad. No se pudo establecer asociación con mortalidad. Conclusiones. La desnutrición es una enfermedad de alta prevalencia en pacientes hospitalizados pero no es diagnosticada frecuentemente. Las medidas antropométricas no son registradas en todas las historias clínicas de los pacientes hospitalizados y se requiere un mayor nivel de sensibilización de los trabajadores de salud para establecer medidas de intervención temprana a fin de obtener mejores desenlaces clínicos.

Objective. To determine the nutritional status and outcomes of patients in 2 hospitals in Villavicencio. Method. Prospective cross-sectional study, survey conducted in two hospitals in Villavicencio, Colombia, on February 24th, 2015. Adult patients from surgical or clinical wards were included. Data was registered in Excel and statistical analysis with SPSS was conducted to determine association between independent variables and outcomes (Mortality and length of stay). Significance was established as p<0,05 with Chi square and Student T test. Results. One hundred and sixteen patients were surveyed. Fifty-six percent of patients were from the public hospital, 58,5% were from surgical wards and 65% were men. Average age was 65,7 (± 20,6) years old. Only 37,1% of the patients had the weight registered in the clinical chart, so nutritional status could be determined in only 31%. Only 23,1% of malnutrition was found, including a 9,5% of underweighted patients. Longer length of stay was found in patients from the public hospital, as well as, under-nutrition, overweight and obesity. No association with mortality was found. Conclusions. Under-nutrition is a prevalent disease in hospitalized patients, but it is not often diagnosed. Anthropometric measures are not registered in all clinical charts of hospitalized patients and it is required a higher level of sensitivity among health care workers, in order to establish early intervention measures, and to get better clinical outcomes.

Objetivo. Estabelecer o estado nutricional em pacientes de dos hospitais de Villavicencio. Metodologia. Estudo de corte transversal, prospectivo, através de pesquisa em 2 hospitais de Villavicencio, Colômbia, em fevereiro de 2015. Pacientes adultos internados em serviços cirúrgicos foram incluídos. Os dados foram registrados em Excel y análise estadística com SPSS foi realizada a fim de encontrar associações entre as variáveis de estudo e os resultados. O nível de significância foi estabelecido quando p<0,05 através do teste Qui Quadrado e a distribuição t de Student. Resultados. 16 pacientes foram entrevistados. 56% dos pacientes eram do hospital público, 58,8% foram de serviços cirúrgicos e 65% eram homens. A idade média foi de 65,7 (20,6 ±) anos. Apenas 37,1% dos pacientes tiveram o peso registado na sua ficha, por isso só foi possível determinar o estado nutricional de 31% dos entrevistados. Foi possível determinar apenas 23,1% de desnutrição, entre os quais havia 9,5% de baixo peso. Os pacientes com maior tempo de internação foram aqueles do hospital público, com desnutrição, sobrepeso e obesidade. Não foi possível estabelecer associação com a mortalidade. Conclusões. A desnutrição é uma doença altamente prevalente em pacientes hospitalizados, mas muitas vezes não é diagnosticada. As medidas antropométricas não são registradas em todas as histórias clínicas de pacientes hospitalizados e um maior nível de sensibilização dos trabalhadores de saúde é necessário para estabelecer medidas de intervenção precoce para obter melhores resultados clínicos.

Disección espontánea de la arteria vertebral / Spontaneous vertebral artery dissection

La disección arterial como causa de ataque cerebrovascular es infrecuente, presentándose más comúnmente en población joven asociado a un trauma menor que involucra la hiperextensión del cuello. Presentamos el reporte de un paciente hombre, joven, con un accidente cerebrovascular de fosa posterior y cuya etiología fue una disección espontánea de la arteria vertebral derecha.

Arterial dissection as a cause of stroke is uncommon, most commonly presenting in young people sometimes associated with trauma involving hyperextension of the neck as the only history which would suggest the traumatic origin. We present the case report of a young man with posterior stroke whose etiology was a spontaneous dissection of the right vertebral artery.

A single subcutaneous dose of tramadol for mild to moderate musculoskeletal trauma in the emergency department.

BACKGROUND: Mild to moderate musculoskeletal trauma is a common cause for an emergency room visit, and frequent pain is one of the cardinal symptoms of consultation. The objective of this study is to assess the perception of a single subcutaneous dose of 50 mg tramadol for pain management in patients with mild to moderate musculoskeletal trauma, likewise to appraise the perception of pain by subcutaneous injection. METHODS: A total of 77 patients, who met inclusion criteria, received a single subcutaneous dose of tramadol. Pain control was evaluated based on the verbal numerical pain scale (0-10) at baseline, 20 and 60 minutes; similarly, pain perception was evaluated secondary to subcutaneous injection of the analgesic. RESULTS: On admission, the average pain perceived by patients was 8; twenty minutes later, 89% of the patients reported five or less, and after sixty minutes, 94% had three or less on the verbal numerical pain scale. Of the patients, 88% reported pain perception by verbal numeric scale of 3 or less by injection of the drug, and 6.5% required a second analgesic for pain control. Two events with drug administration (soft tissue infection and mild abdominal rectus injection) were reported. CONCLUSION: We conclude that a single subcutaneous dose of tramadol is a safe and effective option for the management of patients with mild to moderate pain and musculoskeletal disease in the emergency department.

Neumonía aspirativa por cuerpo extraño en paciente cocainómano y VIH positivo: reporte de caso / Aspiration pneumonia due foreign body in a cocaine user - HIV positive patient: a case report

Son conocidos los efectos del uso de la inhalación de cocaína en diferentes órganos, tales como infartos renales, complicaciones por hipertensión arterial, síndromes coronarios, el pulmón crack, trastornos hidroelectrolíticos, entre otros. No es mucho lo que se sabe sobre la relación entre cuerpos extraños bronquiales y la neumonía aspirativa u obstructiva en pacientes inmunosuprimidos o competentes, siendo en ambos caso de difícil manejo hasta que se descubre la causa subyacente, generalmente por imaginología o fibro-broncospia. En este artículo se describe el caso de un paciente con sida y quien se presenta con una neumonía no resuelta a pesar de tratamiento antibiótico y cuya etiología se debía a un inusual cuerpo extraño bronquial el cual al ser removido llevo a la mejoría clínica del paciente.

Effects of cocaine use are well known in different body organs, for example kidney infartions, hypertension complications, coronary syndromes, the crack lung, electrolyte disorders and others. Not much is known about the relationship between bronchial foreign body aspiration or obstructive pneumonia in immunosuppressed patients. In this paper we describe the case of an aids patient presented with a non-resolved pneumonia despite treatment antibiotic and whose etiology was due an unusual bronchial foreign body. Which removed led to clinical improvement of the patient.

Ultrasound-guided percutaneous drainage of a traumatic abdominal wall hematoma in the emergency department.

BACKGROUND: Abdominal wall hematoma is due to trauma, coagulation disorders or anticoagulation therapy complications. METHODS: In this report we present a case of a 44-year-old female who suffered from blunt abdominal trauma and presented to the emergency department with sharp abdominal pain and ecchymosis. FAST and abdominal computerized tomography (CT) revealed an abdominal wall hematoma. Treatment with an ultrasound-guided percutaneous drainage was performed successfully. RESULTS: The patient remained under observation for six hours with serial ultrasound scans, and no signs of hematoma recurrence were present. She was discharged the same day with clinical improvement. CONCLUSION: Complete history investigation and clinical examination help to make a correct diagnosis of abdominal wall hematoma, select a prompt treatment, and reduce complications.

Polymorphisms in arsenic(+III oxidation state) methyltransferase (AS3MT) predict gene expression of AS3MT as well as arsenic metabolism.

BACKGROUND: Arsenic (As) occurs as monomethylarsonic acid (MMA) and dimethylarsinic acid (DMA) in humans, and the methylation pattern demonstrates large interindividual differences. The fraction of urinary MMA is a marker for susceptibility to As-related diseases. OBJECTIVES: We evaluated the impact of polymorphisms in five methyltransferase genes on As metabolism in two populations, one in South America and one in Southeast Asia. The methyltransferase genes were arsenic(+III oxidation state) methyltransferase (AS3MT), DNA-methyltransferase 1a and 3b (DNMT1a and DNMT3b, respectively), phosphatidylethanolamine N-methyltransferase (PEMT), and betaine-homocysteine methyltransferase (BHMT). AS3MT expression was analyzed in peripheral blood. METHODS: Subjects were women exposed to As in drinking water in the Argentinean Andes [n = 172; median total urinary As (U-As), 200 µg/L] and in rural Bangladesh (n = 361; U-As, 100 µg/L; all in early pregnancy). Urinary As metabolites were measured by high-pressure liquid chromatography/inductively coupled plasma mass spectrometry. Polymorphisms (n = 22) were genotyped with Sequenom, and AS3MT expression was measured by quantitative real-time polymerase chain reaction using TaqMan expression assays. RESULTS: Six AS3MT polymorphisms were significantly associated with As metabolite patterns in both populations (p ≤ 0.01). The most frequent AS3MT haplotype in Bangladesh was associated with a higher percentage of MMA (%MMA), and the most frequent haplotype in Argentina was associated with a lower %MMA and a higher percentage of DMA. Four polymorphisms in the DNMT genes were associated with metabolite patterns in Bangladesh. Noncoding AS3MT polymorphisms affected gene expression of AS3MT in peripheral blood, demonstrating that one functional impact of AS3MT polymorphisms may be altered levels of gene expression. CONCLUSIONS: Polymorphisms in AS3MT significantly predicted As metabolism across these two very different populations, suggesting that AS3MT may have an impact on As metabolite patterns in populations worldwide.

High-level exposure to lithium, boron, cesium, and arsenic via drinking water in the Andes of northern Argentina.

Elevated concentrations of arsenic in drinking water are common worldwide, however, little is known about the presence of other potentially toxic elements. We analyzed 31 different elements in drinking water collected in San Antonio de los Cobres and five surrounding Andean villages in Argentina, and in urine of the inhabitants, using ICP-MS. Besides confirmation of elevated arsenic concentrations in the drinking water (up to 210 microg/L), we found remarkably high concentrations of lithium (highest 1000 microg/L), cesium (320 microg/L), rubidium (47 microg/L), and boron (5950 microg/L). Similarly elevated concentrations of arsenic, lithium, cesium, and boron were found in urine of the studied women (N=198): village median values ranged from 26 to 266 microg/L of arsenic, 340 to 4550 microg/L of lithium, 34 to 531 microg/L of cesium, and 2980 to 16,560 microg/L of boron. There is an apparent risk of toxic effects of long-term exposure to several of the elements, and studies on associations with adverse human health effects are warranted, particularly considering the combined, life-long exposure. Because of the observed wide range of concentrations, all water sources used for drinking water should be screened for a large number of elements; obviously, this applies to all drinking water sources globally.

La reforma de la Seguridad Social en Venezuela: Bases y Perspectivas / Reform of the social security in Venezuela. Basis and perspectives

El presente documento es la Exposición de Motivos del Proyecto de Ley Orgánica del Sistema de Seguridad Social introducido para la discusión en la Asamblea Nacional en el mes de noviembre de 2002. Debido a su importancia, el Comité Editor ha decidido incorporarlo en este Número Extraordinario como un aporte a la discusión que en Venezuela y en toda América Latina se viene desarrollando en torno a este tema. El documento fue elaborado por la Comisión Técnica Asesora de la Comisión de Desarrollo Social Integral, bajo la Coordinación del Dr. Carlos Eduardo Febres y la participación de los expertos: Dr. Alejandro Cardozo por el equipo de Vivienda y Habitat, y Pensiones (fallecido); Dr. Absalón Méndez por el equipo de Pensiones; Soc. Pedro Sassone y Dr. Harald Haljeimer por el equipo de Empleo, Lic. Libertad Polanco por el equipo de Estudios Actuariales; Lic. Vilma Hernández e Ing. Leopoldo Yanes por el Equipo de Seguridad y Salud en el Trabajo, Dres. Edgar Capriles y Mauricio Vegas por el Equipo de Salud, y Lic. José Contreras por la Oficina de Asesoría Económica de la Asamblea Nacional. El documento, en su primera parte hace una revisión de la situación de la Seguridad Social en Venezuela y su impacto en la situación económica y social, tomando como referencia los cambios ocurridos en América Latina en las últimas décadas. En la segunda parte analiza el marco constitucional que sirve de soporte a la propuesta que sustenta el Proyecto de Ley. Una tercera parte desarrolla los contenidos prestacionales y la visión sistémica de la propuesta de seguridad social y en la última parte se desarrolla el impacto económico del Sistema de Seguridad Social tanto desde la perspectiva del Estado como de la de los diferentes componentes