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

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

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

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

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

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

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

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

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

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

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

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

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

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

Basic life support knowledge of secondary school students in cardiopulmonary resuscitation training using a song.

OBJECTIVES: To examine the effectiveness of a "cardiopulmonary resuscitation song" in improving the basic life support skills of secondary school students. METHODS: This pre-test/post-test control design study enrolled secondary school students from two middle schools randomly chosen in Córdoba, Andalucia, Spain. The study included 608 teenagers. A random sample of 87 students in the intervention group and 35 in the control group, aged 12-14 years were selected. The intervention included a cardiopulmonary resuscitation song and video. A questionnaire was conducted at three-time points: pre-intervention, one month and eight months post-intervention. RESULTS: On global knowledge of cardiopulmonary resuscitation, there were no significant differences between the intervention group and the control group in the trial pre-intervention and at the month post-intervention. However, at 8 months there were significant differences with a p-value = 0.000 (intervention group, 95% CI: 6.39 to 7.13 vs. control group, 95% CI: 4.75 to 5.92), F(1,120)=16.644, p=0.000). In addition, significant differences about students' basic life support knowledge about chest compressions at eight months post-intervention (F(1,120)=15.561, p=0.000) were found. CONCLUSIONS: Our study showed that incorporating the song component in the cardiopulmonary resuscitation teaching increased its effectiveness and the ability to remember the cardiopulmonary resuscitation algorithm. Our study highlights the need for different methods in the cardiopulmonary resuscitation teaching to facilitate knowledge retention and increase the number of positive outcomes after sudden cardiac arrest.

Comparison of the Canadian CT head rule and the New Orleans criteria in patients with minor head injury in a Spanish hospital. / Comparación de la regla canadiense y los criterios de New Orleans en el traumatismo craneal leve en un hospital español.

BACKGROUND AND OBJECTIVE: To compare two scales for assessment of patients with mild head injury. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) according to their diagnostic accuracy in patients attending an emergency department, and to determine the most important predictive values. METHOD: Cross-sectional study in a first-level Hospital in the period of January 2011 to January 2013. Patients with mild head injury criteria were included. All the patients underwent a computed tomography (CT) of the head as part of internal protocol and the CCHR and NOC criteria were recorded for each patient. We consider the main variable the presence of traumatic lesions on CT and, as secondary variables, neurosurgical intervention and post-concussion syndrome. Sensitivity, specificity, predictive values and validity index (VI) of the CCHR and the NO criteria in the subgroup of patients with a Glasgow Coma Scale (GCS) score of 15 points were compared. RESULTS: A total of 217 patients, of whom 197 had a GCS score of 15 points were evaluated. Both rules showed 100% sensitivity when a significant injury was presented in the CT, the CCHR 100% (95% CI: 97.4%-100%) and the NO criteria 100% (95% CI: 97.4%-100%); but the CCHR achieved higher values of specificity 25.3% (95% CI: 18.6%-32%), positive predictive value (PPV) and VI. The two rules showed a 100% sensitivity regarding neurosurgical intervention; however the CCHR with high-risk criteria showed better specificity, PPV and VI 55.2 (95% CI: 8.3%-62.2%) compared to the NO criteria 7.6 (95% CI: 3.8%-11.5%). With regard to post-concussion syndrome criteria NO criteria showed better sensitivity 100% (95% CI: 96.2%-100%) and predictive values, but lower specificity and VI compared with the CCHR 76.9% (95% CI: 50.2%-100%). CONCLUSIONS: Our study demonstrates the high sensitivity of the CCHR and the NO criteria in patients with mild head injury, both to detect a significant clinical lesion on CT or the need for neurosurgical intervention and better specificity of CCHR compared with NO criteria. The adoption of clinical prediction rules, especially the CCHR, to request a CT scan in patients with mild head injury should be recommended in the emergency department.

[Emergency department training on the appropriate prescription of anticoagulants in atrial fibrillation and on patient follow-up after discharge]. / Intervención en el servicio de urgencias para lograr un inicio y seguimiento adecuados de la anticoagulación en pacientes con fibrilación auricular.

OBJECTIVES: The main objective was to evaluate the effect of an emergency department training intervention on the use of a protocol for prescribing anticoagulant therapy in atrial fibrillation and on following patients after discharge. MATERIAL AND METHODS: Quasi-experimental pre-post study of a training intervention; the control patients were not matched but were selected consecutively before and after the intervention. All patients were over the age of 18 years, had atrial fibrillation identified by electrocardiogram, and indications for anticoagulant therapy, specifically a score of 2 or more on the CHADS2-DS2-VASc scale (cardiac failure, hypertension, age >75 years, diabetes, stroke [doubled], vascular disease, age 65-74 years, sex). The primary outcome was percentage of patients on anticoagulant therapy on discharge from the department. The secondary outcome was the percentage of patients on therapy 1 month after discharge. RESULTS: A total of 184 patients (86 before the intervention and 98 afterwards) were included. Training significantly increased the prescription of anticoagulants in the department (before the intervention, 32 patients [37%] vs 95 [97%] afterwards; P<.001). In the preintervention period, 26 patients (30% were on anticoagulants 1 month later; in the postintervention period, 26 (30%) were still on therapy (P<.001). CONCLUSION: This study shows that emergency staff training is effective for implementing protocols based on anticoagulant therapy guidelines.

OBJETIVO: Evaluar el resultado de una intervención formativa realizada en el servicio de urgencias (SU), en cuanto a la correcta prescripción y uso de un protocolo de anticoagulación en pacientes con fibrilación auricular (FA) y su posterior seguimiento. METODO: Estudio cuasi-experimental con un grupo de control no equivalente, pre/post intervención formativa. Se seleccionaron dos grupos de pacientes (pre y postintervención) mediante muestreo consecutivo, mayores de 18 años, que se presentaron en el SU con FA identificada en el ECG y con criterios de anticoagulación según la estratificación de riesgo de la escala CHA2DS2-VASc 2. El resultado primario fue la proporción de pacientes anticoagulados al alta del SU. El resultado secundario fue la proporción de pacientes anticoagulados al mes del alta del SU. RESULTADOS: Se incluyeron 184 pacientes (86 preintervención, 98 postintervención). La intervención aumentó de manera significativa el comienzo de la anticoagulación [preintervención 32 (37%) vs postintervención 95 (97%); p < 0,001] y el seguimiento al mes de comenzar el tratamiento [preintervención 26 (30%) vs postintervención 91 (93%); p < 0,001]. CONCLUSIONES: Una intervención formativa en el SU es efectiva para implementar los protocolos adaptados a las guías de práctica clínica de la anticoagulación.

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

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

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