Mixed Adenoneuroendocrine Carcinoma in the Ampulla of Vater: Case Report

A mixed non-neuroendocrine neuroendocrine neoplasm is a mixed neoplasm with a neuroendocrine component combined with a non-neuroendocrine component. It has a low incidence and limited studies, but with evidence of being an aggressive entity associated with poor survival. We present the case of a 58-year-old woman admitted with clinical symptoms of abdominal pain in the left hypochondrium associated with generalized jaundice and feverish spikes with an imaging diagnosis of bile duct dilation secondary to distal choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, finding a significant papilla with a neoplastic appearance, which was biopsied and histopathologically analyzed. The diagnosis of mixed carcinoma with a component of high-grade poorly differentiated neuroendocrine carcinoma and a component of mucinous carcinoma was confirmed. Therefore, we decided to schedule a pancreaticoduodenectomy.

La neoplasia neuroendocrina no neuroendocrina mixta es una neoplasia mixta con un componente neuroendocrino combinado con un componente no neuroendocrino. Esta presenta una incidencia baja y estudios limitados, pero con evidencia de ser una entidad agresiva asociada a una pobre supervivencia. Presentamos el caso de una mujer de 58 años que ingresó por un cuadro clínico de dolor abdominal en el hipocondrio izquierdo asociado a ictericia generalizada y picos febriles con diagnóstico imagenológico de dilatación de la vía biliar secundaria a coledocolitiasis distal, por lo que se realizó una colangiopancreatografía retrógrada endoscópica (CPRE) en la que se encontró una papila mayor de aspecto neoplásico a la cual se le realizó una biopsia analizada histopatológicamente y se confirmó el diagnóstico de carcinoma mixto con componente de carcinoma neuroendocrino pobremente diferenciado de alto grado y componente de carcinoma mucinoso, por lo cual se decidió programar una pancreatoduodenectomía.

A postmortem study of patients vaccinated for SARS-CoV-2 in Colombia.

INTRODUCTION AND OBJECTIVE: A new coronavirus produces a disease designated as coronavirus disease 2019 (COVID-19). Vaccination against COVID-19 has resulted in decreased mortality. Postmortems of vaccinated patients play an important part in the forensic analysis of adverse effects after vaccination, which is essential for determining its efficacy and security. The main objective of this study was to describe the results of autopsies of patients vaccinated for SARS-CoV-2 carried out in two major centers in Colombia. MATERIALS AND METHODS: A descriptive cross-sectional study of 121 autopsies was performed following Colombian regulations in two main hospitals in Bogotá, Colombia, between March 1st and April 31st, 2021. RESULTS: 118 of the 121 patients (97.52%) had been vaccinated with CoronaVac (Sinovac); only 3 had received other vaccines. Sudden cardiac death was the leading cause of death, with pulmonary embolism another critical finding. No relation between the cause of death and vaccination against SARS-CoV-2 was found. CONCLUSIONS: A clinical autopsy is a vital for an accurate post-mortem diagnosis. Any relation between the SARS-CoV-2 vaccine and the cause of death should be carefully studied in order to provide the general public with evidence-based information about the safety of the vaccination.

How Much Do Parents Know About Pain in Their Children?

OBJECTIVES: Adequate pain control is essential to the comprehensive management of pediatric patients within the emergency department.The aim of this study is to evaluate parents' knowledge about pain in the pediatric population patient and secondarily describe erroneous concepts that can affect a correct children's pain management. METHODS: A single-center descriptive study of cross-sectional surveys was performed between October and December 2018, with a previously validated ad hoc and anonymous questionnaire consisting of 9 items. All parents/guardians participating in the study had a child aged 0 to 18 years who had been admitted to the emergency department. RESULTS: Sixty-nine percent (n = 315) were women, 49.9% (n = 226) had university degrees and only 11% (n = 50) had professions related to the healthcare system. A linear association was observed between the number of correct answers and the level of education (ß = 1.04; 95% confidence interval, 0.76-1.32; P < 0.001), as well as between parents with professions related to the healthcare system compared with other professions (61.4% vs 51.2% with P = 0.005). The responses of Spanish parents offered better results than answers obtained from parents from the American continent (56.4% vs 41.4% with P < 0.001). No differences were observed between parents of children with chronic diseases. CONCLUSIONS: In our study, we observed that a considerable percentage of parents hold misconceptions about how children express pain, and therefore, it would be necessary to encourage formation programs for parents to help identify, evaluate, and correctly treat pain in their children.

Pain Prevalence Among Children Visiting Pediatric Emergency Departments.

OBJECTIVES: The main purpose of this study was to investigate the prevalence, characteristics, and intensity of children's pain in emergency departments. The secondary purpose was to evaluate the interobserver agreement regarding the level of pain perceived by professionals, parents, and children. METHODS: This was a multicenter, survey-based research study on 0- to 18-year-old patients visiting 1 of the 15 hospitals that form part of the Working Group on Analgesia and Sedation of the Spanish Society of Pediatric Emergency Medicine between October and December 2018. The surveys recorded pain presence, intensity, characteristics, and location. RESULTS: The study included 1216 surveys. At the time of the interview, 646 patients were experiencing pain, a prevalence of 53.1% (95% confidence interval, 50.3%-55.9%), with 25.38% reporting mild, 36.68% moderate, and 37.46% intense pain. Among the patients, 29.9% had abdominal pain and 14.1% pain in their legs.The pain lasted less than 24 hours in 48.2% of the patients, whereas only 3.0% experienced pain during more than 15 days. The parents of 50.7% of the children had provided an analgesic at home.Interrater agreement regarding pain levels was k = 0.35 between professionals and children, k = 0.38 between children and parents, and k = 0.17 between parents and professionals. For children unable to cooperate, the agreement between professional/child and the parents was k = 0.11. CONCLUSIONS: Pain is a common symptom among emergency department patients, and its evaluation should therefore be obligatory. We found low interrater agreement on pain levels between patients, professionals, and parents, which confirms how difficult it is to accurately evaluate pain intensity.

Analysis of the validity of the five-level TRIPED-GM paediatric triage system.

OBJECTIVE: To determine the validity of the five-level TRIPED-GM pediatric triage system. METHODS: Unicentric, observational, descriptive, cross-sectional study of 485 patients aged 0-16 years in the pediatric emergency department of the HGU Gregorio Marañon. Two measures of validity were used: a direct measure calculated by the sensitivity and specificity obtained based on the number of infratriages and overtriages of the priorities given by classification nurses compared with a panel of experts and another indirect measure by the length of stay, the resources consumed and the percentage of income for each priority level. RESULTS: 10 patients were incorrectly classified, 4 (0.8%) were considered infratriages and 6 (1.2%) overtriages. The results showed a sensitivity of 99.45% (95% CI 96.5-99.97%) and a specificity of 99.01% (95% CI 96.9-99.7%) for high priorities (P2 and P3) and 98.99% (95% CI 96.8-99.6%) and 98.4% (95% CI 96.84-99.74%) respectively for low priorities (P4 and P5). The quadratic weighted Kappa index was 0.96 (95% CI 0.94-0.98; p = 0.0000). Resource consumption showed moderate Spearman correlation coefficients as the priority level increased. The percentage of admissions and the need for observation increased as the priority level p = 0,000 increased, not requiring observation or admitting any patients with priority 5. CONCLUSIONS: The TRIPED-GM pediatric triage system is valid for use in emergency departments with similar patients.

Genome-based local dynamics of canine rabies virus epidemiology, transmission, and evolution in Davao City, Philippines, 2018-2019.

Rabies is a fatal zoonotic and neglected tropical disease caused by the rabies virus (RABV) and is associated with neuronal dysfunction and death, with dogs as the predominant carrier. The Philippines plans to eradicate rabies by 2022, but this is challenged with sub-optimal coverage of vaccination programs coupled with sustained transmission chains, making it unable to eradicate the disease. We investigated the dynamics of canine rabies in the highly urbanized Davao City of the Philippines and its neighboring localities by assessing genetic relationships, transmission patterns, selection pressure, and recombination events using the whole genome sequence of 49 RABV cases from June 2018 to May 2019, majority of which (46%) were from the district of Talomo, Davao City. Although phylogeographic clustering was observed, local variants also exhibited genetic sub-lineages. Phylogenetic and spatial transmission analysis provided evidence for intra- and inter-city transmission predominantly through the Talomo district of Davao City. Around 84% of the cases were owned dogs, but the genetic similiarity of RABVs from stray and owned dogs further alluded to the role of the former as transmission vectors. The high rate of improper vaccination among the affected dogs (80%) was also a likely contributor to transmission. The RABV population under Investigation is generally under strong purifying selection with no evidence of vaccine evasion due to the genetic homogeneity of viruses from vaccinated and improperly vaccinated dogs. However, some homologous recombination (HR) events were identified along the G and L genes, also predominantly associated with viruses from Talomo. The complementary findings on epidemiology, transmission, and recombination for Talomo suggest that high incidence areas can be seeds for virus dispersal and evolution. We recommend further Investigations on the possibility of HR in future large-scale genome studies. Finally, districts associated with these phenomena can be targeted for evidence-based local strategies that can help break RABV transmission chains and prevent emergence of novel strains in Davao City.

ASTRIS, a large real-world study to evaluate the efficacy of osimertinib in epidermal growth factor receptor T790M mutation-positive non-small cell lung cancer patients: Clinical characteristics and genotyping methods in a Spanish cohort.

PURPOSE: Osimertinib has proven efficacy in EGFR T790M mutation-positive non-small cell lung cancer (NSCLC) patients; however, its benefits have not been evaluated in a real-world setting. METHODS: ASTRIS is a single-arm, open-label, multinational study to evaluate the efficacy and safety of osimertinib for the treatment of EGFR T790M mutation-positive NSCLC. We present the study design and preliminary cut-off analysis results (as of October 2017) describing the baseline characteristics and methodology for T790M mutation detection in the Spanish cohort. RESULTS: The Spanish cohort included 131 patients from a total 3014 patients. Forty patients (28.1%) were still undergoing therapy at the time of cut-off; 68.7% were women and 97.7% were Caucasian, with a mean age of 64.8 (SD 11.7) years. The most common type of sample for evaluating T790M mutations was tissue (55.0%), and samples were obtained from the primary tumor in 61.1% of cases. Mutation analysis was performed by the local laboratory in 60.3% of cases and using the Roche Cobas® EGFR assay in 43.5% of cases. CONCLUSIONS: ASTRIS is expected to confirm the benefits of osimertinib in a real-world setting. Data on real-world practices for the detection of the EGFR T790M mutation may provide additional information for the designing of guidelines for best practices.

[Efficacy, safety and satisfaction of sedation-analgesia in Spanish emergency departments]. / Eficacia, seguridad y satisfacción de los procedimientos de sedoanalgesia en las urgencias españolas.

OBJECTIVES: To offer analgesia and sedation should be a priority in paediatric emergency departments. The aim of this study was to determine the effectiveness and safety of the sedation-analgesia procedure, as well as the satisfaction of the doctors, patients and parents. METHODS: A multicentre, observational, and prospective analytical study was conducted on the sedation-analgesia procedure performed on children younger than 18 years old in 18 paediatric emergency departments in Spain from February 2015 until January 2016. RESULTS: A total of 658 procedures were recorded. The effectiveness was good in 483 cases (76.1%; 95%CI: 72.7-79.4%), partial in 138 (21.7%; 95%CI: 18.5-24.9%), and poor in 14 (2.2%; 95%CI: 1.1-3.4). The effectiveness was better when the doctor in charge was an emergency paediatrician (OR: 3.14; 95%CI: 1.10-8.95), and when a deeper level of sedation was achieved (OR: 2.37; 95%CI: 1.68-3.35). Fifty two children (8.4%) developed adverse drug reactions, more usually gastrointestinal, neurological or respiratory ones (89.9% were resolved in <2h). One patient was intubated. The older child and a deeper level of sedation were found to be independent risk factors for adverse reactions (OR: 1.18; 95%CI: 1.09-1.28 and OR: 1.86; 95%CI: 1.22-2.83, respectively). Thirteen children (5%) developed late adverse drug reactions, more commonly, dizziness and nauseas. A combination of midazolam/ketamine had been used in all the cases (RR: 24.46; 95%CI: 11.78-50.76). The perceived satisfaction level (0-10) was obtained from 604 doctors (mean: 8.54; SD: 1.95), 526 parents (mean: 8.86; SD: 1.49), and 402 children (mean: 8.78; SD: 1.70). CONCLUSIONS: The sedation-analgesia procedure performed in paediatric emergency departments by trained paediatricians seems to be useful, effective and safe, as well as satisfactory for all participants.

Eficacia de una intervención educativa para mejorar el conocimiento de las/os enfermeras/os sobre el sondaje gástrico en pediatría / Effectiveness of an educational intervention to improve nurses' knowledge on pediatric nasogastric intubation

Objetivo. Eficacia de una intervención educativa para mejorar el conocimiento de las/os enfermeras/os sobre el sondaje gástrico en pediatría. Métodos. Estudio multicéntrico cuasi experimental pre- y postest mediante intervención educativa teórica basada en la evidencia bibliográfica y la evaluación de su eficacia a los 4 meses. Resultados. Cuestionarios entregados: 1019. Válidos: 557 (54,66 %) pretest, 246 (24,14 %) postest. Las respuestas pre- y postest fueron que el riesgo implícito que conllevaba siempre el procedimiento había sido percibido por el 53,2 % y aumentó al 70,7 % (p < 0,001). El 4,3 % elegía el tamaño de la sonda gástrica (SG) mediante tablas y se elevó al 24,6 % (p < 0,001). La longitud de la SG por introducir medida mediante el método nariz-oreja-distancia media xifoides-ombligo (nose-ear-mid-umbilicus; NEMU, por sus siglas en inglés) ascendió del 34,2 % al 81,3 % (p < 0,001). La comprobación de la ubicación de la SG previa a su uso pasó del 73,1 % al 86,5 % (p < 0,001). La comprobación de los cinco correctos (paciente, medicamento, dosis, vía y hora) previa a la utilización de la SG aumentó del 85,6 % al 91 %. Como métodos de comprobación, mejoró la percepción de inseguridad de la auscultación del 11,7 % al 31,1 % (p < 0,001), y disminuyó su uso del 95,1 % al 81,6 %. Creció la percepción de seguridad de la medición del pH gástrico del 71,3 % al 91,1 % (p < 0,001), y aumentó su uso del 7,6 % al 54,3 % (p < 0,001). Conclusiones. La intervención educativa resultó eficaz para incrementar el conocimiento de enfermería sobre el sondaje gástrico pediátrico.

Objective. To establish the effectiveness of an educational intervention to improve nurses' knowledge on pediatric nasogastric intubation. Methods. Multicenter, quasi-experimental, pre- and post-test study using a theoretical educational intervention based on bibliographic evidence and assessment of its effectiveness after 4 months. Results. Delivered questionnaires: 1019. Valid questionnaires: 557 (54.66 %) pre-test and 246 (24.14 %) post-test. Pre- and post-test answers indicated that the implied risk always entailed by the procedure had been perceived by 53.2 % and then increased to 70.7 % (p < 0.001). Nasogastric (NG) tube size was chosen using tables by 4.3 % of participants, and increased to 24.6 % (p < 0.001). The length of NG tube to be inserted as measured by the nose-ear-midumbilicus distance (NEMU) method increased from 34.2 % to 81.3 % (p < 0.001). Confirmation of NG tube placement prior to use increased from 73.1 % to 86.5 % (p < 0.001). Confirmation of the five rights (patient, drug, dosage, route, and timing) prior to NG tube use increased from 85.6 % to 91 %. In relation to confirmation methods, the perception that auscultation was unsafe improved from 11.7 % to 31.1 % (p < 0.001), and its use reduced from 95.1 % to 81.6 %. The perception that the measurement of gastric pH was safe increased from 71.3 % to 91.1 % (p < 0.001), and its use rose from 7.6 % to 54.3 % (p < 0.001). Conclusions. The educational intervention was effective to increase nurses' knowledge on pediatric nasogastric intubation.

Effectiveness of an educational intervention to improve nurses' knowledge on pediatric nasogastric intubation. / Eficacia de una intervención educativa para mejorar el conocimiento de las/os enfermeras/os sobre el sondaje gástrico en pediatría.

OBJETIVE: To establish the effectiveness of an educational intervention to improve nurses' knowledge on pediatric nasogastric intubation. METHODS: Multicenter, quasi-experimental, pre- and post-test study using a theoretical educational intervention based on bibliographic evidence and assessment of its effectiveness after 4 months. RESULTS: Delivered questionnaires: 1019. Valid questionnaires: 557 (54.66 %) pre-test and 246 (24.14 %) post-test. Pre- and post-test answers indicated that the implied risk always entailed by the procedure had been perceived by 53.2 % and then increased to 70.7 % (p < 0.001). Nasogastric (NG) tube size was chosen using tables by 4.3 % of participants, and increased to 24.6 % (p < 0.001). The length of NG tube to be inserted as measured by the nose-ear-midumbilicus distance (NEMU) method increased from 34.2 % to 81.3 % (p < 0.001). Confirmation of NG tube placement prior to use increased from 73.1 % to 86.5 % (p < 0.001). Confirmation of the five rights (patient, drug, dosage, route, and timing) prior to NG tube use increased from 85.6 % to 91 %. In relation to confirmation methods, the perception that auscultation was unsafe improved from 11.7 % to 31.1 % (p < 0.001), and its use reduced from 95.1 % to 81.6 %. The perception that the measurement of gastric pH was safe increased from 71.3 % to 91.1 % (p < 0.001), and its use rose from 7.6 % to 54.3 % (p < 0.001). CONCLUSIONS: The educational intervention was effective to increase nurses' knowledge on pediatric nasogastric intubation.

Objetivo. Eficacia de una intervención educativa para mejorar el conocimiento de las/os enfermeras/os sobre el sondaje gástrico en pediatría. Métodos. Estudio multicéntrico cuasi experimental pre- y postest mediante intervención educativa teórica basada en la evidencia bibliográfica y la evaluación de su eficacia a los 4 meses. Resultados. Cuestionarios entregados: 1019. Válidos: 557 (54,66 %) pretest, 246 (24,14 %) postest. Las respuestas pre- y postest fueron que el riesgo implícito que conllevaba siempre el procedimiento había sido percibido por el 53,2 % y aumentó al 70,7 % (p < 0,001). El 4,3 % elegía el tamaño de la sonda gástrica (SG) mediante tablas y se elevó al 24,6 % (p < 0,001). La longitud de la SG por introducir medida mediante el método nariz-oreja-distancia media xifoides-ombligo (nose-ear-mid-umbilicus; NEMU, por sus siglas en inglés) ascendió del 34,2 % al 81,3 % (p < 0,001). La comprobación de la ubicación de la SG previa a su uso pasó del 73,1 % al 86,5 % (p < 0,001). La comprobación de los cinco correctos (paciente, medicamento, dosis, vía y hora) previa a la utilización de la SG aumentó del 85,6 % al 91 %. Como métodos de comprobación, mejoró la percepción de inseguridad de la auscultación del 11,7 % al 31,1 % (p < 0,001), y disminuyó su uso del 95,1 % al 81,6 %. Creció la percepción de seguridad de la medición del pH gástrico del 71,3 % al 91,1 % (p < 0,001), y aumentó su uso del 7,6 % al 54,3 % (p < 0,001). Conclusiones. La intervención educativa resultó eficaz para incrementar el conocimiento de enfermería sobre el sondaje gástrico pediátrico.

The Knowledge of and Attitudes Toward First Aid and Cardiopulmonary Resuscitation Among Parents.

PURPOSE: To determine the level of knowledge of first aid and cardiopulmonary resuscitation (CPR) among the parents of children who attended our Pediatric Emergency Department and to identify the factors that affect this knowledge. DESIGN AND METHODS: Descriptive, transversal study. A questionnaire was distributed anonymously among parents to collect data about their previous CPR training, knowledge and experience. RESULTS: A total 405 valid questionnaires were returned. The mean age of the sample was 38.08 (SD 7.1) years, and 66.9% of participants were female. The mean score of correctly answered questions was 6.76 out of 19 questions. Parents with a university education received a mean score of 7.16 versus 6.24 for those with a primary education (p = 0.022). Parents with previous training received a higher mean score (8.04 vs 6.17, respectively, p < 0.01). Parents with jobs related to healthcare or education received a higher mean score compared to those who did not (8.63, p < 0.01 and 7.16, p = 0.0013, respectively). No significant differences among parents with chronically ill children (p = 0.76) or related to the number of children (ρ = -0.101) were observed. Furthermore, 77.3% of parents expressed an interest in receiving further training. CONCLUSIONS: Knowledge of first aid among the general population is lacking. Parents with previous training in this field, those with a university-level education, and those who are healthcare providers and educational professionals received significantly higher scores. PRACTIC IMPLICATIONS: Studies based on surveys can be useful in estimating a population's knowledge base, allowing the development of community-based training activities.

Evaluación del manejo del dolor de la patología facial y oral en un Servicio de Urgencias Pediátrico y tras el alta domiciliaria / Assessment of orofacial pain management in a pediatric emergency department and at home after discharge

Introducción. El manejo inadecuado del dolor es frecuente en Urgencias. El objetivo fue analizar el manejo del dolor de niños con patología infecciosa o traumática del área facial/oral en Urgencias y evaluar el cumplimiento y satisfacción sobre la analgesia prescrita al momento del alta. Población y métodos. Estudio transversal, observacional y analítico en niños que acudieron a Urgencias con patología infecciosa/traumática de la región facial/oral durante 2 meses. Se recogieron el manejo del dolor en Urgencias, la analgesia prescrita para el domicilio y, tras el contacto telefónico con los padres, el tratamiento realizado y su adecuación al dolor del niño. Resultados. Fueron incluidos 252 pacientes (edad media de 4,5 años, desvío estándar 3,89). En 8,7%, figuraba la evaluación del dolor en triaje y, en 3,6%, en el informe médico. Se administró analgesia en Urgencias al 41,3%. Al momento del alta, en un 13,9%, no se prescribió analgesia; en 25,4%, se prescribió pautada y, en 60,3%, a demanda. Los pediatras usaron más analgesia pautada que los cirujanos (34,4% vs. 16,5%, p < 0,01). En el domicilio, no administraron analgesia en el 39,3%; en un 36,1%, pautada y, en un 23%, a demanda. Existió escasa correlación entre la pauta al momento del alta y la administrada en el domicilio (kappa: 0,178). Se consideró la analgesia adecuada en el 84%, con más frecuencia en patología traumática que infecciosa (85,7% vs. 14,3%, p < 0,01). Conclusiones. Se observó escasa evaluación y tratamiento del dolor en Urgencias. La prescripción más usada fue a demanda en vez de pautada, al contrario de lo recomendado en las guías. El control analgésico fue mejor en patología traumática que infecciosa.

Introduction. An inadequate pain management is common in the emergency department. Our objective was to analyze pain management among children with an orofacial infection or trauma in the emergency department and to assess compliance and satisfaction with analgesia prescribed at discharge. Population and methods. Cross-sectional, observational and analytical study in children attending the emergency department for an orofacial infection or trauma over 2 months. Pain management in the emergency department, analgesia prescribed at home and, following a call to parents, treatment provided and its adequacy to control pain were registered. Results. In total, 252patients (mean age: 4.5 years, SD: 3.89) were included. Pain assessment was recorded at the triage for 8.7%, and in the medical report, for 3.6%. Analgesia was administered to 41.3% in the emergency room. At discharge, no analgesia was prescribed to 13.9%; scheduled analgesia, to 25.4%; and as needed, to 60.3%. Pediatricians prescribed scheduled analgesia more frequently than surgeons (34.4% versus 16.5%, p < 0.01). At home, no analgesia was administered to 39.3%; scheduled analgesia, to 36.1%; and as needed, to 23%. There is little correlation between prescription at discharge and at home (Kappa: 0.178). Analgesia was considered adequate in 84% of cases, and was more frequent in trauma injuries than in infections (85.7% versus 14.3%, p < 0.01). Conclusions. Pain assessment and management was scarce in the emergency department. The most common prescription was as needed, contrary to what is recommended in the guidelines. Analgesic control worked better for trauma injuries than for infections.

Assessment of orofacial pain management in a pediatric emergency department and at home after discharge. / Evaluación del manejo del dolor de la patología facial y oral en un Servicio de Urgencias Pediátrico y tras el alta domiciliaria.

INTRODUCTION: An inadequate pain management is common in the emergency department. Our objective was to analyze pain management among children with an orofacial infection or trauma in the emergency department and to assess compliance and satisfaction with analgesia prescribed at discharge. POPULATION AND METHODS: Cross-sectional, observational and analytical study in children attending the emergency department for an orofacial infection or trauma over 2 months. Pain management in the emergency department, analgesia prescribed at home and, following a call to parents, treatment provided and its adequacy to control pain were registered. RESULTS: In total, 252patients (mean age: 4.5 years, SD: 3.89) were included. Pain assessment was recorded at the triage for 8.7%, and in the medical report, for 3.6%. Analgesia was administered to 41.3% in the emergency room. At discharge, no analgesia was prescribed to 13.9%; scheduled analgesia, to 25.4%; and as needed, to 60.3%. Pediatricians prescribed scheduled analgesia more frequently than surgeons (34.4% versus 16.5%, p < 0.01). At home, no analgesia was administered to 39.3%; scheduled analgesia, to 36.1%; and as needed, to 23%. There is little correlation between prescription at discharge and at home (Kappa: 0.178). Analgesia was considered adequate in 84% of cases, and was more frequent in trauma injuries than in infections (85.7% versus 14.3%, p < 0.01). CONCLUSIONS: Pain assessment and management was scarce in the emergency department. The most common prescription was as needed, contrary to what is recommended in the guidelines. Analgesic control worked better for trauma injuries than for infections.

INTRODUCCIÓN: El manejo inadecuado del dolor es frecuente en Urgencias. El objetivo fue analizar el manejo del dolor de niños con patología infecciosa o traumática del área facial/oral en Urgencias y evaluar el cumplimiento y satisfacción sobre la analgesia prescrita al momento del alta. POBLACIÓN Y MÉTODOS: Estudio transversal, observacional y analítico en niños que acudieron a Urgencias con patología infecciosa/traumática de la región facial/oral durante 2 meses. Se recogieron el manejo del dolor en Urgencias, la analgesia prescrita para el domicilio y, tras el contacto telefónico con los padres, el tratamiento realizado y su adecuación al dolor del niño. RESULTADOS: Fueron incluidos 252 pacientes (edad media de 4,5 años, desvío estándar 3,89). En 8,7%, figuraba la evaluación del dolor en triaje y, en 3,6%, en el informe médico. Se administró analgesia en Urgencias al 41,3%. Al momento del alta, en un 13,9%, no se prescribió analgesia; en 25,4%, se prescribió pautada y, en 60,3%, a demanda. Los pediatras usaron más analgesia pautada que los cirujanos (34,4% vs. 16,5%, p < 0,01). En el domicilio, no administraron analgesia en el 39,3%; en un 36,1%, pautada y, en un 23%, a demanda. Existió escasa correlación entre la pauta al momento del alta y la administrada en el domicilio (kappa: 0,178). Se consideró la analgesia adecuada en el 84%, con más frecuencia en patología traumática que infecciosa (85,7% vs. 14,3%, p < 0,01). CONCLUSIONES: Se observó escasa evaluación y tratamiento del dolor en Urgencias. La prescripción más usada fue a demanda en vez de pautada, al contrario de lo recomendado en las guías. El control analgésico fue mejor en patología traumática que infecciosa.

[Knowledge of nurses about medication doses at pediatric urgency departament]. / Conocimiento de las enfermeras de las dosis de medicamentos en urgencias de pediatría.

UNLABELLED: Errors in drug administration are the second cause of errors in hospitalized patients. Children are a high risk group. Besides, pressure in care interventions at emergency department leads to increase incidence errors. AIM: Determining nurses' knowledge about the most common drug doses at pediatric urgency department. METHODS: Descriptive transversal study. We collected data from nurses of 14 pediatric emergency departments of Madrid. With an "ad hoc" questionnaire we collected the following data during five days in January of 2014: demographic, knowledge of responsibility in administration and doses of drugs. Global descriptive analysis was made and it was stratified by hospital and work experience. RESULTS: The answer rate was 114 (34.9%). Only 80 (70.8%) of nurses confirm doses before their administration; 20 (18.6%) think that a wrong prescription that they administer is not their responsibility. There is a high knowledge in the group with more than five years of work experience, except for sedative-analgesic drugs (p<0.05). The average score obtained was 3.8 of 10 (1.99). CONCLUSIONS: Nurses' knowledge about drug doses is low.

[Pulmonary arterial hypertension, a rare entity]. / Hipertensión arterial pulmonar, una entidad rara.

Pulmonary arterial hypertension (PAH) is a rare disease. It is characterized by the progressive remodeling of the small pulmonary arteries that lead to an elevation of the pulmonary vascular resistance and right ventricular dysfunction. Early diagnosis and prompt treatment avoid the deterioration of the patient's quality of life. Statistics show that there are 15 cases per million people worldwide, the majority comprised of young women, with an age at diagnosis of 30 to 40 years. At present, the exact processes that initiate the pathophysiologic changes observed in PAH are unknown; it is thought to be multifactorial. Diagnosis in PAH must be done in a step by step manner. Under the suspicion of pulmonary hypertension (PH), the first thing to do is confirm the diagnosis. The second step is to identify the specific etiology and lastly evaluate the severity by echocardiography, hemodynamic parameters, biomarkers and exercise capacity. PH treatment, particularly PAH, has evolved over the last 2 decades due to the advance in disease knowledge and the availability of agents that act on different pathways. Concerning surgical treatment, it is indicated in PAH when there is not an adequate response to medical treatment. In conclusion, PAH is recognized worldwide as a rare or infrequent disease. The countries that have a registry for the diagnostics, treatment, follow-up and prevalence of PH are mainly in Europe. With the exception of the United States and Canada, there are no registries in America. Recent years have shown an important advance in Latin America.

[NASO-OROGASTRIC TUBE IN PAEDIATRIC PATIENTS. REVIEW OF METHODS OF CONFIRMATION OF PLACEMENT]. / Sondaje naso/orogástrico en el paciente pediátrico.

Nasogastric tube (NGT) placement is a frequent procedure in the paediatric population. Nasogastric and orogastric tubes are commonly used in hospitalized children, in the paediatric emergency departments and in critical care departments. They have diagnostic, therapeutic, descompression or evacuation of gastric aspirates objectives. Making a blind placement of nasogastric tubes, involve that nasogastric tube could be misplaced in 4.7 % to 69 % of cases. An accurate method for confirmation of nasogastric tube positioning is therefore needed. Chest X-ray remains the only hundred per cent reliable method (gold standard), but it only confirms tube positioning at the exact time of the X-ray. Non-radiologic verification methods provide an accurate alternative and contribute to decrease radiation exposure for pediatric patients. Non-radiologic methods to verify appropiate placement of tubes are many and are supported by different degrees of evidence in the literature: measurement of tube length from point of entry; auscultation; placing the tube in water to assess bubbling; aspiration of stomach or intestinal contents for visual inspection; pH testing; use of CO2 monitoring devices, or combinations of these methods. In this article we thoroughly review the reliability and safety of these non radiologic methods for the verification of nasogastric tube placement.

Manejo del síndrome caquexia-anorexia en el cáncer avanzado / Management cachexia-anorexia syndrome in advanced cancer

El síndrome de caquexia-anorexia (SCA) afecta aproximadamente al 80% de los pacientes con cáncer avanzado cercanos al final de la vida. La incidencia y la gravedad del SCA aumentan a medida que progresa la enfermedad primaria. En los últimos años se han producido grandes avances en el conocimiento de la fisiopatología y múltiples opciones terapéuticas para el SCA. Para hacer un uso racional de los avances terapéuticos, consideramos necesario hacer una distinción entre dos extremos diferentes en la evolución del SCA. Por un lado, consideraremos al paciente con SCA en etapa precoz, con diagnóstico de cáncer reciente, en tratamiento oncológico activo, buen performance status y posibilidades de curación o supervivencia prolongada. En esta situación clínica proponemos el uso racional e intensivo de todas las medidas basadas en la evidencia tendientes a corregir el SCA: suplementos dietarios, alimentación artificial, orexígenos, ejercicio, etc. En el otro extremo, encontramos al paciente caquéctico con cáncer avanzado, pérdida de peso progresiva, profunda astenia, pobre performance status, con escasa ingesta vía oral, enfermedad en progresión y una expectativa de vida corta. En esta situación, algunos tratamientos como la alimentación artificial carecen de utilidad e incluso podrían empeorar algunos síntomas físicos. Por lo tanto, el abordaje más apropiado para el manejo del SCA avanzado podría ser aquel orientado a mejorar la calidad de vida, priorizar el control de síntomas (anorexia, náuseas, vómitos, astenia, xerostomía, etc.), preservar la ingesta por vía oral y brindar contención emocional al paciente y su familia En este artículo, abordaremos el tratamiento paliativo del SCA en paciente con cáncer avanzado.

Cachexia-anorexia syndrome (CAS) affects approximately80% of advanced cancer patients near end of life. Incidenceand severity of CAS increase as primary disease progressesIn the last few years great advances has been made in theunderstanding of the pathophysiology and treatment ofCAS. To make a rational use of therapeutic advances, weconsider necessary to distinguish between two differentextremes in the evolution of CAS. On one hand, we willconsider the patient with CAS in early phase, recentlydiagnosed cancer, with active oncologic treatment, goodperformance status and chances of cure or prolongedsurvival. In this clinical setting, we propose the rationaland intensive use of all evidence-based measures directedto correct CAS: dietary supplements, artificial nutrition,orexigenics, exercise, etc. On the other hand, we find thecachectic patient with advanced cancer, progressive weightloss, profound asthenia, poor performance status, little oralintake, progressive disease and a short life expectancy. Inthis stage, some treatments like artificial nutrition lack ofutility and could even worsen some physical symptoms.Therefore, the more appropriate approach to advancedCAS could be that one oriented to improve quality of life,prioritize symptoms control (anorexia, nausea and vomiting,asthenia and xerostomy), to preserve oral intake andto provide emotional support to the patient and the family.In this article, we will focus on palliative treatment of CASin the patient with advanced cancer.

Miotonía de Thomsen y embarazo, manejo anestésico: reporte de un caso / Myotonia of Thomsen and pregnancy, anesthetic management: a case report

La miotonía de Thomsen es una enfermedad autosómica dominante que consiste en una marcada hipertrofia muscular a predominio en miembros superiores, que se encuentra asociada a una alteración en los canales de cloruro que intervienen en el potencial de acción del músculo esquelético, dicha enfermedad ha sido vinculada con complicaciones anestésicas como episodios de hipertermia maligna. Se presenta el caso de una paciente de 20 años, IIG, IC, con embarazo de 38 semanas, y diagnóstico de miopatía de Thomsen para resolución obstétrica electiva por vía alta. Se discuten los aspectos clínicos de la enfermedad y su manejo anestésico

Thomsen myotonia is a autosomal dominant disease which consists in marked muscular hypertrophy with dominance in the upper limbs associated with disturbance in the chloride channels involved in the skeletal muscle action potential. This disease has been linked with anesthetic complications such as malignant hyperthermia episodes. Is a patient of 20 years old, IIG, IC, with 38 weeks pregnancy, and diagnosis of myopathy of Thomsen for elective obstetrical resolution by cesarean section. The clinical aspects of the disease and its anaesthetic management are discussed