Síndrome de la costilla deslizante en la edad pediátrica. Serie de casos / Slipping rib syndrome in childhood. A case series

Entre las causas de dolor torácico, la costilla deslizante presenta baja prevalencia, antecedentes traumáticos y manejo controvertido. Este síndrome merece ser incluido en el diagnóstico diferencial de causas de dolor torácico en niños. Al no asociarse a traumatismos previos y la deformidad de cartílagos, nos induce a pensar en una alteración en el desarrollo costal, al margen de la etiología traumática típica en adultos. Se presenta una serie de pacientes pediátricos intervenidos por costilla deslizante en un centro de referencia entre 2001 y 2022. Se incluyeron nueve pacientes, con un rango de edades de 11 a 16 años. Solo dos casos describen traumatismo previo. Todos presentan un inicio súbito de dolor toracoabdominal intenso. Los pacientes fueron intervenidos mediante resección abierta de cartílagos costales afectos, con resolución del dolor.

Among the causes of chest pain, slipping rib has a low prevalence, usually with a history of trauma, and its management is controversial. Slipping rib syndrome should be included in the differential diagnosis of causes of chest pain in children. When not associated with previous trauma and cartilage deformity, it is necessary to consider an alteration in rib development, regardless of the typical traumatic etiology in adults. Here we describe a series of pediatric patients with slipping rib seen at a referral hospital between 2001 and 2022. Nine patients aged 11 to 16 years were included. Only 2 had a history of trauma. All patients described a sudden onset of severe thoracic abdominal pain. The patients underwent open resection of the affected costal cartilages, with resolution of pain.

Dor torácica em pacientes com transtorno do pânico e cardiopatia isquêmica em emergência / Chest pain in patients with panic disorder and ischemic heart path in emergency

Introdução: Dor torácica é um sintoma geralmente presente em ambientes de atendimento emergencial. Objetivo: Verificar as características da dor torácica derivada do transtorno de pânico e da cardiopatia isquêmica, se a equipe multiprofissional acredita que existe diferença entre os sinais e sintomas, se sabem o tratamento, encaminhamento e desfecho dos pacientes. Método: Estudo transversal, com abordagem quantitativa, delineamento descritivo analítico, com correlação entre as variáveis, realizado por meio de questionário com 77 profissionais de uma equipe multiprofissional do Pronto Atendimento da Emergência de um hospital de ensino, no ano de 2022. Resultados: Pacientes com queixa de dor torácica eram atendidos imediatamente seguindo protocolo específico, que envolve repouso absoluto, medicação, oxigenoterapia, eletrocardiograma, monitorização cardíaca e exames laboratoriais. A maioria dos profissionais relatou que existe diferença entre os sinais e sintomas da dor decorrente de pânico e da cardiopatia isquêmica, mas destacou que há pontos comuns, e o conjunto de sintomas físicos e psicológicos confunde a equipe e dificulta o diagnóstico. A maioria conhecia o fluxo, encaminhamento e tratamento dos pacientes coronariopatas, mas não sabiam o tratamento e encaminhamento para aqueles com transtorno do pânico, pois recebiam alta hospitalar da emergência para casa, sem avaliação de um especialista e sem orientações sobre o problema. Destacaram que a comunicação efetiva auxilia na detecção tanto de problemas físicos, como de sofrimentos emocionais, sendo crucial para o tratamento e a assistência. Conclusão: Os participantes do estudo demonstraram conhecimento e preparo para atender as condições da dor torácica dos pacientes, independente da origem, acreditam que há diferença na apresentação da dor, relacionada a irradiação para braço e pescoço, mas se confundem, o que dificulta o diagnóstico e o tratamento, especialmente quando é pânico. O serviço e a equipe carecem de profissionais especializados em saúde mental e psiquiatria para tratamento e encaminhamento adequado dos acometidos pelo transtorno de pânico.

Introduction: Chest pain is a symptom generally present in emergency care environments. Objective: To verify the characteristics of chest pain resulting from panic disorder and ischemic heart disease, whether the multidisciplinary team believes that there is a difference between signs and symptoms, whether they know the treatment, referral and outcome of patients. Method: Cross-sectional study, with a quantitative approach, analytical descriptive design, with correlation between variables, carried out through a questionnaire with 77 professionals from a multidisciplinary team from the Emergency Department of a teaching hospital, in the year 2022. Results: Patients with complaints of chest pain were treated immediately following a specific protocol, which involves absolute rest, medication, oxygen therapy, electrocardiogram, cardiac monitoring and laboratory tests. Most professionals reported that there is a difference between the signs and symptoms of pain resulting from panic and ischemic heart disease, but highlighted that there are common points, and the set of physical and psychological symptoms confuses the team and makes diagnosis difficult. The majority knew the flow, referral and treatment of patients with coronary artery disease, but they did not know the treatment and referral for those with panic disorder, as they were discharged from the emergency room to home, without evaluation by a specialist and without guidance on the problem. They highlighted that effective communication helps to detect both physical problems and emotional suffering, being crucial for treatment and assistance. Conclusion: The study participants demonstrated knowledge and preparation to deal with the conditions of patients' chest pain, regardless of the origin, they believe that there is a difference in the presentation of pain, related to irradiation to the arm and neck, but it is confused, which makes diagnosis difficult and treatment, especially when it is panic. The service and team lack professionals specialized in mental health and psychiatry for treatment and appropriate referral of those affected by panic disorder

Introducción: El dolor torácico es un síntoma generalmente presente en ambientes de atención de emergencia. Objetivo: Verificar las características del dolor torácico derivado del trastorno de pánico y de la cardiopatía isquémica, si el equipo multidisciplinario cree que existe diferencia entre signos y síntomas, si conoce el tratamiento, derivación y evolución de los pacientes. Método: Estudio transversal, con enfoque cuantitativo, diseño analítico descriptivo, con correlación entre variables, realizado a través de un cuestionario a 77 profesionales de un equipo multidisciplinario del Servicio de Emergencia de un hospital universitario, en el año 2022. Resultados: Los pacientes con quejas de dolor torácico fueron tratados inmediatamente siguiendo un protocolo específico, que incluye reposo absoluto, medicación, oxigenoterapia, electrocardiograma, monitorización cardíaca y pruebas de laboratorio. La mayoría de los profesionales informaron que existe diferencia entre los signos y síntomas del dolor por pánico y la cardiopatía isquémica, pero resaltaron que hay puntos en común, y el conjunto de síntomas físicos y psicológicos confunde al equipo y dificulta el diagnóstico. La mayoría conocía el flujo, derivación y tratamiento de los pacientes con enfermedad coronaria, pero desconocía el tratamiento y derivación de aquellos con trastorno de pánico, ya que eran dados de alta de urgencia a su domicilio, sin evaluación de un especialista y sin orientación sobre el problema. Destacaron que la comunicación efectiva ayuda a detectar tanto problemas físicos como sufrimiento emocional, siendo crucial para el tratamiento y asistencia. Conclusión: Los participantes del estudio demostraron conocimiento y preparación para afrontar las condiciones de dolor torácico de los pacientes, independientemente del origen, creen que existe diferencia en la presentación del dolor, relacionado con la irradiación al brazo y cuello, pero pero obtienen confuso, lo que dificulta el diagnóstico y el tratamiento, especialmente cuando se trata de pánico. El servicio y el equipo carecen de profesionales especializados en salud mental y psiquiatría para el tratamiento y derivación adecuada de los afectados por el trastorno de pánico

Protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en el diagnóstico del dolor torácico: una revisión sistemática / Accelerated Diagnostic Protocols Based on High-Sensitivity Troponin in the Diagnosis of Thoracic Pain: A Systematic Review

RESUMEN Introducción: Los protocolos de diagnóstico acelerado de dolor torácico, con el avance de la troponina de alta sensibilidad, permiten identificar a los pacientes que ingresan al servicio de urgencias con dolor torácico de bajo riesgo para un evento cardiovascular adverso mayor, que podrían ser dados de alta de forma temprana y segura, con ahorro de tiempo y recursos. Objetivo: Evaluar ensayos clínicos que utilicen protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad. Material y métodos: se realizó una búsqueda de ensayos clínicos aleatorizados que evaluaran protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en los servicios de urgencias, en las bases de datos MEDLINE/Ovid, Cochrane y EMBASE utilizando los criterios de evaluación del manual Cochrane y la estrategia PRISMA Resultados: Tras una tamización de 3509 estudios se incluyeron 5 ensayos clínicos que incluyeron 1513 pacientes; se identificaron 409 (27%) altas tempranas, el 91% para el protocolo 0/3 h ESC, 72% para el 0/1 h, 48% para el EDACS, 40% para el HEART, 19 y 32% para ADAPT y 8 y 18% para el cuidado usual. El valor predictivo negativo fue alto, en un rango de 99,1 al 100% La duración media de la estancia hospitalaria fue más baja para los protocolos 0/1 h y 0/3 h ESC, con 4,6 y 5,6 horas respectivamente. Conclusiones: Los protocolos de diagnóstico acelerado en dolor torácico que implementan el uso de troponina de alta sensibilidad permiten lograr alta proporción de altas tempranas con baja tasa de eventos cardiovasculares mayores, con disminución del tiempo de estancia y recursos consumidos.

ABSTRACT Background: Accelerated diagnostic protocols for chest pain, with the advancement of high-sensitivity troponin, make it possible to identify patients admitted to the emergency department with chest pain and low risk for a major adverse cardiovascular event, who could be discharged immediately, early and safely, saving time and resources. Objective: The aim of this study was to assess clinical trials using accelerated diagnostic protocols based on high-sensitivity troponin. Methods: A search of randomized clinical trials evaluating accelerated diagnostic protocols based on high-sensitivity troponin in emergency services was carried out in MEDLINE/Ovid, Cochrane and EMBASE database, using the assessment criteria of the Cochrane manual and the PRISMA strategy. Results: After screening 3509 studies, 5 clinical trials, including 1513 patients, were analyzed. Early discharges were identified in 409 (27%) of patients, in 91% of cases for ESC 0/3-h protocols, 72% for 0/1-h, 48% for EDACS, 40% for HEART, 19% and 32% for ADAPT and 8% and 18% for standard care protocols. The negative predictive value was high, in the 99.1-100% range. Mean length of hospital stay was lower for the 0/1-h and ESC 0/3-h protocols, with 4.6 and 5.6 hours, respectively. Conclusions: Accelerated diagnostic protocols in chest pain using high-sensitivity troponin allow a higher proportion of early discharges with a low rate of major cardiovascular events, with reduction in length of hospital stay and resources used.

Hallazgos ergoespirométricos en un paciente con fístula coronaria / Cardiopulmonary exercise test findings in a patient with a coronary fistula

Resumen En la práctica médica es común encontrar retos en el diagnóstico de los pacientes. Este es un caso que realiza un cuadro clínico de una mujer con síntomas de dolor torácico y disnea de esfuerzo con diagnóstico final de una rara presentación de fístula coronaria, a quien se le realizaron múltiples estudios cardiovasculares descritos, como métodos no invasivos para el hallazgo de dicha alteración, sin llegar a un diagnóstico, para, finalmente, realizar el procedimiento estándar de oro, como lo es la arteriografía coronaria, por los resultados anormales de la ergoespirometría indicada por disnea de etiología no clara.

Abstract In medical practice, it is common to encounter challenges in the diagnosis of patients. The case report gives a detailed description of the clinical history of a young adult female patient who presented the cardinal warning signs of chest pain and longstanding dyspnea on exertion and was ultimately diagnosed with a rare presentation of a coronary fistula. The patient had previously undergone multiple cardiovascular tests described in the medical literature as a non-invasive means for identifying this disorder (conventional stress test, transthoracic echocardiogram, and myocardial perfusion), but with no definitive diagnosis. Finally, she underwent coronary arteriography, the gold standard procedure, due to her abnormal results on the cardiopulmonary exercise test (CPET), which was ordered due to dyspnea of unclear etiology.

Improvement in the management of suspected acute aortic syndrome in the emergency room through a clinical algorithm and study of predictive factors.

BACKGROUND AND OBJECTIVE: Acute aortic syndrome (AAS) is uncommon and difficult to diagnose, with great variability in clinical presentation. To develop a computerized algorithm, or clinical decision support system (CDSS), for managing and requesting imaging in the emergency department, specifically computerized tomography of the aorta (CTA), when there is suspicion of AAS, and to determine the effect of implementing this system. To determine the factors associated with a positive radiological diagnosis that improve the predictive capacity of CTA findings. MATERIALS AND METHODS: After developing and implementing an evidence-based algorithm, we studied suspected cases of AAS. Chi-squared test was used to analyze the association between the variables included in the algorithm and radiological diagnosis, with 3 categories: no relevant findings, positive for AAS, and alternative diagnoses. RESULTS: 130 requests were identified; 19 (14.6%) had AAS and 34 (26.2%) had a different acute pathology. Of the 19 with AAS, 15 had been stratified as high risk and 4 as intermediate risk. The probability of AAS was 3.4 times higher in patients with known aortic aneurysm (P = .021, 95% CI 1.2-9.6) and 5.1 times higher in patients with a new aortic regurgitation murmur (P = .019, 95% CI 1.3-20.1). The probability of having an alternative severe acute pathology was 3.2 times higher in patients with hypotension or shock (P = .02, 95% CI 1.2-8.5). CONCLUSION: The use of a CDSS in the emergency department can help optimize AAS diagnosis. The presence of a known aortic aneurysm and new-onset aortic regurgitation were shown to significantly increase the probability of AAS. Further studies are needed to establish a clinical prediction rule.

Estratificación de riesgo del dolor torácico en el servicio de urgencia / Risk stratification of chest pain in the emergency department

El dolor torácico es un motivo de consulta frecuente en los servicios de urgencia. Su espectro de presentaciones y su diagnóstico diferencial es amplio, con patologías de elevada morbilidad y mortalidad asociadas. Es el síntoma principal en pacientes con un síndrome coronario agudo y, ante su sospecha es mandatorio realizar una evaluación inicial centrada en la estratificación de riesgo de sufrir eventos adversos en cada paciente, para así definir su tratamiento y disposición posterior de forma correcta. Objetivo: presentar los elementos que componen la evaluación inicial del dolor torácico ante una sospecha de síndrome coronario agudo y las herramientas disponibles para realizar la estratificación de riesgo y así guiar la disposición desde el servicio de urgencia. Método: Se realizó una revisión bibliográfica de la literatura sobre la estratificación de riesgo del dolor torácico, buscando la evidencia actual respecto a las herramientas diagnósticas utilizadas habitualmente en el servicio de urgencia. Resultados: Se presenta una revisión con generalidades del dolor torácico, sus diagnósticos diferenciales, los elementos de la evaluación inicial y las herramientas clínicas para la evaluación de riesgo de pacientes con dolor torácico y sospecha de síndrome coronario agudo en el servicio de urgencia. Discusión y conclusiones: La presentación del síndrome coronario agudo es variable en la población. Ante la presencia de un cuadro de dolor atípico y/o un electrocardiograma no diagnóstico, recomendamos el uso de un sistema de puntaje validado como el HEART / HEART pathway para reducir la posibilidad de una inadecuada estratificación de riesgo en el servicio de urgencia

Chest pain is a common complaint in emergency departments. The spectrum of presentation and its differential diagnosis are broad, including pathologies associated with high morbidity and mortality, and it is the main symptom in patients suffering from acute coronary syndrome. If suspected, it is mandatory to work out an initial evaluation focused on the risk stratification of adverse events for each patient to define their correct treatment and disposition. Objective: show the elements that involve the initial evaluation of chest pain suspicious of an acute coronary syndrome, the clinical tools available to perform risk stratification, and guide the disposition from the emergency department. Method: a review of the literature on chest pain risk stratification was performed, looking for current evidence of the most commonly used diagnostic tools in emergency departments. Results: we present a literature review of generalities about chest pain and its differential diagnoses, the elements to consider in the initial evaluation, and clinical tools for risk stratification of patients with suspected acute coronary syndrome at the emergency department. Discussion and conclusions: the presentation of acute coronary syndrome is variable in the population. In the presence of atypical chest pain or a non-diagnostic electrocardiogram, we recommend using a validated score as the HEART / HEART Pathway to reduce the chance of inadequate risk stratification in the emergency department.

Dolor torácico agudo en pacientes jóvenes: reporte de dos casos / Acute chest pain in young patients: report of two cases

Se presentan dos casos clínicos de pacientes jóvenes con dolor torácico agudo, en ellos, el enfoque multidisciplinario y la resonancia magnética cardíaca jugaron un papel crucial en el diagnóstico y tratamiento. Presentación del caso 1. Un paciente de 20 años con dolor precordial y palpitaciones que mostró elevación de los niveles de enzimas cardíacas en los exámenes de laboratorio. La angiografía coronaria no reveló estenosis significativas. Sin embargo, se confirmó el diagnóstico de miocarditis a través de la resonancia magnética cardíaca, lo que llevó al inicio del tratamiento con medicamentos para lograr una función cardíaca adecuada y la prevención del progreso de la enfermedad. Su evolución clínica fue favorable. Presentación del caso 2. Un paciente de 19 años que presentó un dolor torácico intenso que se irradiaba al brazo izquierdo y mandíbula. Los exámenes de laboratorio reportaron elevación de los niveles de troponinas, que generaron la sospecha de un síndrome coronario agudo. La resonancia magnética cardíaca confirmó el diagnóstico de un infarto agudo de miocardio, y la angiografía coronaria reveló una estenosis significativa en la arteria descendente anterior y una ectasia subsiguiente. Durante la hospitalización, se brindó un enfoque terapéutico integral con la administración de medicamentos, monitoreo, control del dolor y prevención de complicaciones, y el paciente mostró una evolución clínica favorable

Two clinical cases of young patients with acute chest pain are presented, where the multidisciplinary approach and cardiac magnetic resonance played a crucial role in diagnosis and treatment. Case presentation 1. A 20 year old patient with precordial pain and palpitations showed elevated cardiac enzyme levels on laboratory examination. Coronary angiography revealed no significant stenosis. However, the diagnosis of myocarditis was confirmed by cardiac magnetic resonance imaging, which led to the initiation of drug treatment to achieve adequate cardiac function and prevention of disease progression. His clinical evolution was favorable. Case presentation 2. 19 year old patient presented with severe chest pain radiating to the left arm and jaw. Laboratory tests reported elevated troponin levels, which raised the suspicion of acute coronary syndrome. Cardiac magnetic resonance imaging confirmed the diagnosis of acute myocardial infarction, and coronary angiography revealed significant stenosis in the anterior descending artery and subsequent ectasia. During hospitalization, a comprehensive therapeutic approach with medication administration, monitoring, pain control, and prevention of complications was provided, and the patient showed a favorable clinical evolution

Chest pain secondary to drug use treated in hospital emergency departments in Spain.

OBJECTIVE: To determine the characteristics of patients with chest pain (CP) associated with recent drug use. METHODS: Study of cases from the REUrHE registry attended in the emergency department of 11 Spanish hospitals for CP following recreational drug use. RESULTS: CP accounted for 8.97% of attendances (males 82.9%, p<0.001). Cocaine was present in 70% of cases, followed by cannabis (35.7%) and amphetamines and derivatives (21.4%). The most frequent initial symptoms were: palpitations (45.5%, p<0.001), anxiety (42.5%, p<0.001), hypertension (13.6%, p<0.001) and arrhythmias (5.9%, p<0.001). Patients with TD received more treatment (81.9% vs 74.1%; p<0.001), although they were admitted less (7.6%, p=0.0), with no differences in terms of CPR manoeuvres, sedation, intubation, or admission to intensive care (1.9%). CONCLUSIONS: In CP following acute drug intoxication, cocaine use predominates, although cases of cannabis use are increasing.

Prediction of adverse cardiac outcomes in high-risk Mexican patients with chest pain in the emergency department / Desenlaces adversos cardiovasculares en pacientes mexicanos de alto riesgo con dolor torácico en el servicio de urgencias

Abstract Objective: The aim of the study was to compare the discriminative power and accuracy for prediction of MACE of five commonly used scoring tools in Mexican patients with chest pain who present to the ED. Methods: A single-center, prospective, observational, and comparative study of patients admitted to the ED with chest pain as the chief complaint. Five chest pain scoring systems were calculated. The primary endpoint was the composite of cardiovascular death, myocardial infarction, coronary intervention, coronary artery bypass grafting, or readmission for cardiovascular causes within 30 days. Results: A total of 168 patients were studied. The score which provided the highest area under the curve of 0.76 (95% CI: 0.70-0.85) was history, ECG, age, risk factors, and troponin (HEART) score. In addition, the integrated discrimination index for the HEART score was 6% higher when compared to the other four scores. Conclusions: The HEART score provided the best classification tool for identifying those patients at highest risk for MACE, either alone or by adding their results to other classification scores, even in a comorbid population.

Resumen Objetivo: Comparar el poder discriminativo y precisión diagnóstica de Eventos Cardiovasculares Mayores (ECVM) de cinco escalas de clasificación de dolor torácico de uso común en pacientes mexicanos con dolor torácico que acuden al servicio de urgencias. Métodos: Estudio prospectivo, observacional y comparativo que incluyó a pacientes ingresados en urgencias que presentaban dolor torácico como síntoma cardinal. Se calcularon cinco escalas de puntuación de dolor torácico. El desenlance principal fue el compuesto de muerte cardiovascular, infarto de miocardio, intervención coronaria, injerto de derivación de arteria coronaria o reingreso por causas cardiovasculares dentro de los 30 días. Resultados: Se estudió un total de 168 pacientes. La escala de puntuación que proporcionó el área bajo la curva más alta de 0.76 (IC de 95%: 0.70-0.85) fue la escala de historia clínica, ECG, edad, factores de riesgo y troponina (HEART, por sus siglas en inglés). Además, el indice de discriminación efectiva para la puntuación HEART fue un 6% más alto en comparación con las otras cuatro escalas de puntuación. Conclusiones: La escala de HEART proporcionó la mejor herramienta de clasificación para idenfiticar a los pacientes con mayor riesgo de ECVM, ya sea solo a agregando sus resultados a otros puntajes de clasificación, incluso en una población comórbida.

Pleural appendages: Description, incidence and relations with body mass index

BACKGROUND AND AIMS: Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients. PATIENTS AND METHODS: Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax. Patients were divided in obese (BMI>30) and non-obese (BMI<30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering p<0.05 as significant. RESULTS: Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n=31). Most were located in the cardiophrenic angle (n=27), and most measured <5cm (n=39). There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (p=0.315), number (p=0.458) and size (p=0.458). CONCLUSIONS: Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.

Prediction of adverse cardiac outcomes in high-risk Mexican patients with chest pain in the emergency department.

OBJECTIVE: The aim of the study was to compare the discriminative power and accuracy for prediction of MACE of five commonly used scoring tools in Mexican patients with chest pain who present to the ED. METHODS: A single-center, prospective, observational, and comparative study of patients admitted to the ED with chest pain as the chief complaint. Five chest pain scoring systems were calculated. The primary endpoint was the composite of cardiovascular death, myocardial infarction, coronary intervention, coronary artery bypass grafting, or readmission for cardiovascular causes within 30 days. RESULTS: A total of 168 patients were studied. The score which provided the highest area under the curve of 0.76 (95% CI: 0.70-0.85) was history, ECG, age, risk factors, and troponin (HEART) score. In addition, the integrated discrimination index for the HEART score was 6% higher when compared to the other four scores. CONCLUSIONS: The HEART score provided the best classification tool for identifying those patients at highest risk for MACE, either alone or by adding their results to other classification scores, even in a comorbid population.

OBJETIVO: Comparar el poder discriminativo y precisión diagnóstica de Eventos Cardiovasculares Mayores (ECVM) de cinco escalas de clasificación de dolor torácico de uso común en pacientes mexicanos con dolor torácico que acuden al servicio de urgencias. MÉTODOS: Estudio prospectivo, observacional y comparativo que incluyó a pacientes ingresados en urgencias que presentaban dolor torácico como síntoma cardinal. Se calcularon cinco escalas de puntuación de dolor torácico. El desenlance principal fue el compuesto de muerte cardiovascular, infarto de miocardio, intervención coronaria, injerto de derivación de arteria coronaria o reingreso por causas cardiovasculares dentro de los 30 días. RESULTADOS: Se estudió un total de 168 pacientes. La escala de puntuación que proporcionó el área bajo la curva más alta de 0.76 (IC de 95%: 0.70-0.85) fue la escala de historia clínica, ECG, edad, factores de riesgo y troponina (HEART, por sus siglas en inglés). Además, el indice de discriminación efectiva para la puntuación HEART fue un 6% más alto en comparación con las otras cuatro escalas de puntuación. CONCLUSIONES: La escala de HEART proporcionó la mejor herramienta de clasificación para idenfiticar a los pacientes con mayor riesgo de ECVM, ya sea solo a agregando sus resultados a otros puntajes de clasificación, incluso en una población comórbida.

[Entrapment syndromes of the intercostal nerve and its branches]. / Síndromes por atrapamiento del nervio intercostal y sus ramas.

Musculoskeletal chest pain poses a broad differential diagnosis, among which intercostal nerve involvement stands out. Its entrapment or that of any of its branches can resemble visceral pain and therefore can easily go unnoticed. With a good examination and the use of dynamic ultrasound, the diagnostic approach can be simpler. We present a 40-year-old man evaluated in a rehabilitation department for right lower rib pain, triggered by certain movements and associated with a pectus excavatum type thoracic deformity. Using dynamic ultrasound maneuvers, he was diagnosed with neuralgia of the 7th right intercostal nerve secondary to dynamic entrapment in the context of a thoracic deformity with costal hypermobility. We describe the clinical presentation, ultrasound imaging, treatment, and evolution after treatment. In this case, we describe entrapment syndromes of the intercostal nerve and its branches, their clinical and ultrasound diagnosis, and their therapeutic approach.

Factors associated with erroneous emergency department noncardiac chest pain classifications in men and women. / Análisis individualizado por sexo de los factores asociados a la clasificación inicial errónea en urgencias del dolor torácico como no coronario.

OBJECTIVES: To analyze the frequency and clinical characteristics associated with erroneous initial classifications of noncardiac chest pain (NCP) in men and women. MATERIAL AND METHODS: We analyzed all case records in which chest pain was initially classified as noncardiac in origin according to clinical signs and electrocardiograms evaluated in our emergency department between 2008 and 2017. We considered the initial evaluation of NCP to be in error if the final diagnosis was acute coronary syndrome. A risk model for an erroneous initial classification of NCP was developed based on multivariable analysis of our patient data. We also used multivariable analysis to explore associations between 10 clinical signs of chest pain and an erroneous initial NCP classification. The data for men and women were analyzed separately. RESULTS: NCP was the initial classification for 8093 women; their median (interquartile range) age was 54 (38-73) years. The classification was in error for 72 women (0.9%). Odds ratios (ORs) showed that patient risk factors associated with an erroneous NCP classification in the women in our series were obesity (OR, 0.40; 95% CI, 0.17- 0.97) and cocaine consumption (OR, 5.18; 95% CI, 1.16-23.2). Clinical risk factors associated with erroneous NCP classification in women were recent physical exertion (OR, 2.01; 95% CI, 1.21-3.33), radiation exposure (OR, 2.05; 95% CI, 1.23-3.41), and vegetative symptoms (OR, 1.86; 95% CI, 1.02-3.41). For 9979 men with a median age of 47 (33-64) years, NCP was the initial classification; in 83 of the men (0.8%) the classification was erroneous. Patient factors associated with erroneous NCP classification in men were age over 40 years (OR, 1.74; 95% CI, 1.04-2.91) and hypertension (OR, 0.45; 95% CI, 0.24-0.84). No clinical signs of chest pain in men were associated with error. CONCLUSION: More clinical characteristics are associated with an erroneous classification of NCP in women. Our findings underline the need to assess the possibility of acute coronary syndrome differently in women, in whom the signs have usually been considered to be atypical.

OBJETIVO: Analizar de forma independiente en mujeres y hombres la frecuencia y las características clínicas asociadas a una clasificación inicial errónea (CIE) en urgencias del dolor torácico (DT) como no coronario. METODO: Se analizan todas las consultas por DT atendidas en urgencias entre 2008 y 2017 clasificadas inicialmente (historia clínica y ECG) como DT no coronario. Se consideró como CIE si el diagnóstico final fue síndrome coronario agudo (SCA). Se crearon dos modelos multivariable, uno con 10 factores de riesgo, y otro con 10 características clínicas del DT, en los que se investigó la asociación de estas variables con una CIE. Se analizaron independientemente mujeres y hombres. RESULTADOS: Se analizaron 8.093 mujeres con DT clasificado inicialmente como no coronario (edad mediana: 54 años, RIC: 38-73), 72 con CIE (0,9%). Los factores de riesgo asociados independientemente a CIE fueron obesidad (OR = 0,40; IC 95% = 0,17-0,97) y consumo de cocaína (5,18; 1,16-23,2), y las características clínicas fueron relación con el esfuerzo (2,01; 1,21-3,33), existencia de irradiación (2,05; 1,23-3,41) y síntomas vegetativos acompañantes (1,86; 1,02-3,41). Se analizaron 9.979 hombres (edad mediana: 47 años, RIC: 33-64), 83 con CIE (0,8%). Los factores de riesgo asociados a CIE fueron edad > 40 años (1,74; 1,04-2,91) e hipertensión (0,45; 0,24-0,84). No hubo características clínicas del DT asociadas a CIE. CONCLUSIONES: En las mujeres con dolor torácico, se idenfitican más características asociadas al error de clasificación que en los hombres. Este estudio remarca la necesidad de análisis independiente por sexo en el SCA, en el que clásicamente se ha considerado la clínica en las mujeres como atípica.

Factor de crecimiento de hepatocitos séricos como herramienta diagnóstica en pacientes con dolor torácico agudo / Serum hepatocyte growth factor as diagnostic tool in patients with acute chest pain

Resumen Objetivo Determinar si los niveles plasmáticos de factor de crecimiento de hepatocitos podrían ayudar a realizar el diagnóstico diferencial en pacientes con dolor torácico prolongado y elevación de la troponina cardiaca, y evaluar su valor pronóstico de mortalidad al año en estos pacientes. Método: Estudio prospectivo observacional. Se incluyeron pacientes mayores de 18 años que acudieron a urgencias con dolor torácico agudo de más de 20 minutos y elevación de la troponina cardiaca, con seguimiento al año. Resultados Se incluyeron 303 pacientes, 103 (34%) con infarto de miocardio y 200 (66%) con otras enfermedades. Los niveles plasmáticos del factor de crecimiento de hepatocitos fueron superiores en el grupo sin infarto de miocardio: 329 pg/ml (rango intercuartílico [IQR]: 66-558) vs. 476 pg/ml (IQR: 264-908; p < 0.001). La mortalidad al año fue del 30.7%, superior en el grupo sin infarto de miocardio (36.5% vs. 19.4%; p = 0.002). Se encontró una fuerte asociación entre la mortalidad y los niveles elevados de factor de crecimiento de hepatocitos (650 pg/ml [344-1159] vs. 339 pg/ml [205-607]; p < 0.001). En el análisis multivariado se halló que los niveles de factor de crecimiento de hepatocitos, la edad y la escala GRACE son factores independientes de mortalidad al año en estos pacientes. Conclusiones En los pacientes con dolor torácico agudo prolongado y elevación de la troponina cardiaca, la determinación de los niveles del factor de crecimiento de hepatocitos no permite confirmar ni descartar la presencia de infarto agudo de miocardio. No obstante, podría ser un marcador pronóstico de mortalidad en estos pacientes, junto con la edad y la escala GRACE.

Abstract Objective To determine if plasma levels of hepatocyte growth factor could help in the differential diagnosis of patients with prolonged chest pain and elevated cardiac troponin; and to evaluate its prognostic value for one-year mortality in these patients. Method A prospective observational study. Patients over the age of 18 who were seen in the emergency room for acute chest pain lasting longer than 20 minutes and elevated cardiac troponin were included, with follow up after one year. Results We included 303 patients, 103 (34%) with myocardial infarction and 200 (66%) with other diseases. Plasma levels of hepatocyte growth factor were higher in the group without myocardial infarction: 329 pg/ml (IQR: 166-558) vs. 476 pg/ml (IQR: 264-908; p < 0.001). One-year mortality was 30.7%, higher in the group without myocardial infarction (36.5% vs. 19.4%; p = 0.002). We found a strong association between mortality and elevated levels of hepatocyte growth factor (650 pg/ml [344-1,159] vs. 339 pg/ml [205-607]; p < 0.001). Multivariate analysis showed that levels of hepatocyte growth factor, age and the GRACE scale are independent factors for one-year mortality in these patients. Conclusions In patients with prolonged acute chest pain and elevated cardiac troponin, hepatocyte growth factor levels do not confirm or rule out acute myocardial infarction, although they may be a prognostic marker for mortality in these patients, along with age and the GRACE scale.

Síndrome de Dressler: el retorno de una enfermedad olvidada / Dressler's syndrome: the return of a forgotten entity

Resumen El síndrome de Dressler es una enfermedad infrecuente que fue descrita por primera vez en 1956 por el doctor William Dressler. Corresponde a un cuadro de pericarditis secundaria, en ocasiones asociada a efusión pericárdica de aparente etiología autoinmunitaria, que hace parte de los síndromes de lesión poscardiaca. Se presenta un caso de síndrome de Dressler en un paciente joven.

Abstract Dressler's syndrome is a rare entity which was first described in 1956 by Dr. William Dressler. It consists of secondary pericarditis, at times associated with pericardial effusion with an apparently autoimmune etiology, which is one of the post-cardiac injury syndromes. We present a case of Dressler's syndrome in a young patient.

Caracterización del dolor torácico agudo en pacientes del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández. Matanzas / Characterization of acute chest pain in patients of the Teaching Clinic- Surgical Hospital Comandante Faustino Perez Hernandez. Matanzas

RESUMEN Introducción: el dolor torácico agudo es una sensación dolorosa que se manifiesta entre el diafragma y la base del cuello. En Cuba, constituye una de las causas más frecuentes de consulta médica. La provincia de Matanzas muestra un comportamiento similar. Objetivo: caracterizar el perfil clínico de los pacientes con dolor torácico agudo en la Unidad de Cuidados Intensivos Emergentes, del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, de Matanzas. Materiales y métodos: se realizó un estudio transversal descriptivo con las historias clínicas de 418 pacientes que acudieron a la Unidad de Cuidados Intensivos Emergentes, refiriendo dolor torácico agudo, de enero a diciembre de 2019. Resultados: el rango de edad más afectado fue el de 50 a 59 años, para un 30,38 %. Predominó el sexo masculino con el 30,08 %. El ejercicio físico intenso elevó el riesgo de aparición de dolor torácico. Las primeras causas de dolor torácico agudo fueron, en orden de frecuencia, la osteocondritis esternocostal, la bursitis del hombro y el síndrome coronario agudo. Conclusiones: se evidenció que en la mayoría de los casos el origen del dolor fueron causas no cardiovasculares, afectando más al sexo masculino. Existió asociación estadística significativa entre la actividad física intensa y el inicio del dolor torácico agudo. Egresaron vivos de la unidad el 71,53 % de los pacientes. Se recomienda priorizar la atención de los pacientes que refieren dolor torácico agudo, para una correcta clasificación y atención en el menor tiempo posible (AU).

ABSTRACT Introduction: acute chest pain is a painful sensation perceptible between the diaphragm and the base of the neck. It is one of the most frequent causes of medical consultation in Cuba. It shows a similar behavior in the province of Matanzas. Objective: to characterize the clinical profile of the patients with acute thoracic pain in the Emergency Intensive Care Unit of the Teaching Clinic-Surgical Hospital Comandante Faustino Perez Hernandez, of Matanzas. Materials and methods: a descriptive, cross-sectional study was carried out with the clinical records of 418 patients who attended the Emergency Intensive Care Unit referring acute thoracic pain, from January to December 2019. Results: the most affected age range was the one from 50 to 59 years, for 30.38 %. Male sex predominated, with 30.08 %. Intense physical exercise raised the risk of thoracic pain. The first causes of acute thoracic pain were, in order of frequency, sternocostal osteochondritis, shoulder bursitis, and acute coronary syndrome. Conclusions: It was evidenced that in most of the cases the source of the pain was non-cardiovascular causes, more affecting the male sex. There was significant statistic association between intense physical activity and acute thoracic pain. 71.53 % of the patients was discharged from the unit alive. It is recommended to prioritize the attention of patients referring acute thoracic pain, for their correct classification and care in the shortest possible time (AU).

Protocolo de recepción del paciente con síndrome coronario agudo en el Servicio de Urgencia / Adulto Reception protocol for patients with acute coronary syndrome in the Adult Emergency Service

El Síndrome coronario agudo (SCA) se define como la obstrucción brusca de una arteria que puede dar lugar a una isquemia miocárdica aguda que se acompaña de un síndrome clínico característico que puede ir desde una isquemia con elevación o sin elevación en el segmento ST, angina estable o inestable y muerte súbita. Dado que el SCA es considerado un problema mundial por su alta incidencia y una de las principales causas de muerte es que resulta indispensable la creación y aplicación de un protocolo de recepción del paciente con SCA donde el enfermero que recepciona al paciente con dolor torácico en un servicio de urgencia pueda realizar la valoración de forma oportuna y rápida teniendo en cuenta una secuencia de intervenciones y cuidados que se encuentren plasmados en una planilla el cual garantice la implementación de las medidas terapéuticas a tiempo, aumentando la eficacia de las mismas, reduciendo la morbimortalidad y disminuyendo los costos hospitalarios. El objetivo del protocolo es estandarizar las intervenciones y cuidados de enfermería en la atención inicial del paciente con SCA[AU]

Acute coronary syndrome (ACS) is defined as a sudden obstruction of an artery that can lead to acute myocardial ischemia that is accompanied by a characteristic clinical syndrome that can range from elevation or without elevation ischemia in the ST segment, angina stable or unstable and sudden death. Ince ACS is considered a worldwide problem due to its high incidence and one of the main causes of death, it is essential to create and apply a protocol for receiving the patient with ACS, where the nurse who receives the patient with chest pain in a The emergency service can carry out the assessment in a timely and fast way, taking into account a sequence of interventions and care that are reflected in a schedule that guarantees the implementation of therapeutic measures in time, increasing their effectiveness, reducing morbidity and mortality. and lowering hospital costs. The objective of the protocol is to standardize nursing interventions and care in the initial care of the patient with ACS[AU]

A síndrome coronariana aguda (SCA) é definida como uma obstrução repentina de uma artéria que pode levar a isquemia miocárdica aguda, acompanhada por uma síndrome clínica característica que pode variar de elevação ou sem isquemia de elevação no segmento ST, angina morte estável ou instável e repentina.Como a SCA é considerada um problema mundial devido à sua alta incidência e uma das principais causas de morte, é essencial criar e aplicar um protocolo para receber o paciente com SCA, onde a enfermeira que recebe o paciente com dor no peito O serviço de emergência pode realizar a avaliação de maneira oportuna e rápida, levando em consideração uma sequência de intervenções e cuidados que se refletem em um cronograma que garante a implementação de medidas terapêuticas no tempo, aumentando sua efetividade, reduzindo a morbimortalidade. e redução de custos hospitalares. O objetivo do protocolo é padronizar intervenções e cuidados de enfermagem nos cuidados iniciais do paciente com SCA[AU]

The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient.

BACKGROUND: Breast cancer is the most commonly occurring cancer among women. Among its treatment sequelae is chronic neuropathic pain after breast surgery (CNPBS). Pain management is difficult and classicaly consists in a pharmacological approach, however recent studies have advocated the use of locoregional techniques as adjuvants. Serratus plane block (SPB) has recently emerged as a potential tool for the control of CNPBS. This study aims to evaluate the efficacy and potencial role of the ultrasound-guided SPB on CNPBS. METHODS: A retrospective analysis was performed on 30 patients with CNPBS refractory to drug therapy, who underwent SPB between 2017-2019. The following parameters were analyzed: basal pain, pain at 24 h, 1 week and at 1 month. The Mann-Whitney test was applied. Statistical significance was considered at the level of p < 0.05. All statistical analysis was performed with SPSS 20. RESULTS: 3 patients were excluded. At 24 h, we report pain improvement (at least 30% reduction on basal pain score) on 20 patients and after 1 week on 12. At 1 month after, 22 patients had improved, from these: 11 improved with no therapeutic adjustment; 11 patients improved with therapeutic adjustment (8 in gabapentinoid monotherapy, 3 with introduction of polytherapy). 5 patients didn't improve. CONCLUSION: Our study demonstrated SPB as a valid alternative for CNPBS management when pharmacologic therapy has been proven insufficient, with no side effects reported. Randomized studies are needed to assess the magnitude of SPB on CNPBS and to identify the patients who benefit the most from SPB.

Extrapleural fat: description, incidence, and relation with body mass index. / Apéndices pleurales: descripción, incidencia y relación con el índice de masa corporal.

BACKGROUND AND AIMS: Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients. PATIENTS AND METHODS: Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax. Patients were divided in obese (BMI > 30) and non-obese (BMI < 30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering p<0.05 as significant. RESULTS: Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n=31). Most were located in the cardiophrenic angle (n=27), and most measured < 5cm (n=39). There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (p=0.315), number (p=0.458) and size (p=0.458). CONCLUSIONS: Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.

Predictors of primary percutaneous coronary intervention delay in cases of myocardial infarction diagnosed in hospitals without hemodynamic support systems / Predictores de demora en el intervencionismo coronario percutáneo primario en el infarto de miocardio diagnosticado en hospitales sin hemodinámica.

OBJECTIVES: The need for primary percutaneous coronary intervention in hospitals without hemodynamic support capability is associated with delays between first medical contact (FMC) and reperfusion. It is important to identify factors involved in delays, particularly if they are relevant to the organization of emergency services. MATERIAL AND METHODS: Analysis of a registry of patients treated in hospitals without advanced hemodynamic support systems in a catchment area with an established care network for acute ST-segment elevation myocardial infarction (STEMI). The registry included care times. RESULTS: The network served 2542 patients with a mean (SD) age of 63 (13) years. FMC-to-reperfusion time was within 120 minutes in 42% of the cases. Nine of the hospitals had a chest-pain unit in the emergency department, and this factor was an independent predictor of FMC-to-reperfusion times of 120 minutes or less (odds ratio, 0.64; 95% CI, 0.54­0.77; P < .0001); the time was shortened by 11 minutes in such hospitals. FMC-to-reperfusion was delayed beyond 120 minutes in relation to the following factors: shock and need for intubation at start of care, age, gender, FMC at night, left bundle branch block, and Killip class. One-month and 1-year mortality rates increased in hospitals without hemodynamic support systems in proportion to reperfusion delay, by 1.7% and 3.5% if the delay was 106 minutes or less and by 7.3% and 12.4% if the delay was 176 minutes or longer (P < .0001). CONCLUSION: FMC-to-reperfusion time in STEMI exceeds recommendations in 58% of the hospitals without hemodynamic support systems and delay is inversely proportional to the availability of an emergency department chest pain unit. One-month and 1-year mortality is proportional to the degree of delay.

OBJETIVO: La indicación de intervencionismo coronario percutáneo primario (ICPP) en hospitales sin hemodinámica (HSH) se asocia con tiempos primera asistencia-apertura de la arteria (TPA) prolongados. Es pertinente identificar los factores implicados, especialmente aquellos relacionados con la organización de los servicios de urgencias. METODO: Análisis de un registro de pacientes atendidos en HSH en una región sanitaria con una red asistencial para infarto agudo de miocardio con elevación del segmento ST (IAMEST) establecida y de sus tiempos de actuación. RESULTADOS: En 2.542 pacientes, de edad 63 ± 13 años, se alcanzó un TPA 120 minutos en un 42% de casos. En 9 de los 16 HSH analizados existía un box de dolor torácico en el área de urgencias, que se comportó como factor predictor independiente de un TPA 120 minutos [OR 0,64 (IC 95% 0,54-0,77), p 0,001], con una reducción de 11 minutos de este. Se asociaron de forma independiente con un TPA superior a 120 minutos la intubación y shock durante la primera asistencia, edad, sexo, atención en horario nocturno, bloqueo de rama izquierda y la clase Killip. La mortalidad al mes y al año aumentó en los HSH proporcionalmente al TPA (1,7% y 3,5% si TPA 106 minutos y del 7,3% y 12,4% si TPA 176 minutos, p 0,001). CONCLUSIONES: El TPA alcanzado en activaciones procedentes de HSH supera las recomendaciones en el 58% de casos y se relaciona inversamente con la disponibilidad de un box de dolor torácico en urgencias. La mortalidad al mes y al año es proporcional al grado de retraso en la reperfusión.