Manejo de los pacientes con fibrilación auricular en los servicios de urgencias hospitalarios (actualización 2012) / Atrial fibrillation management in the hospital emergency department: 2012 update

La fibrilación auricular (FA) es la arritmia sostenida de mayor prevalencia en los servicios de urgencias (SHU), que presentan una frecuentación elevada y creciente en España. La FA es una enfermedad grave, que incrementa la mortalidad y asocia una relevante morbilidad e impacto en la calidad de vida de los pacientes y en el funcionamiento de los servicios sanitarios. La diversidad de aspectos clínicos a considerar y el elevado número de opciones terapéuticas posibles justifican la implementación de estrategias de actuación coordinadas entre los diversos profesionales implicados, con el fin de incrementar la adecuación del tratamiento y optimizar el uso de recursos. Este documento recoge las recomendaciones para el manejo de la FA, basadas en la evidencia disponible, y adaptadas a las especiales circunstancias de los SUH. En él se analizan con detalle las estrategias de tromboprofilaxis, control de frecuencia y control del ritmo, y los aspectos logísticos y diagnósticos relacionados (AU)

Atrial fibrillation is the most frecuently sustained arrhythmia managed in emergency departments, and accounts for a high and increasing prevalence in Spain. Atrial fibrillation is increases mortality, is associated with substantial complications and, therefore, has a relevant impact in running of the health care system. Management requires consideration of diverse clinical variables and a large number of possible therapeutic approaches, justifying action plans that coordinate the work of medical staff in the interest of providing appropriate care and optimizing resources. These evidence-based guidelines contain recommendations for managing atrial fibrillation in the special circumstances of hospital emergency departments. Stroke prohylaxis, rate control, rhtyhm control, and related diagnostic and logistic issues are discussed in detail (AU)

Mortalidad precoz en un hospital terciario: análisis de la calidad asistencial / Early mortality in a tertiary care hospital: analysis of quality of care

Objetivos: Describir y analizar las características clínico-epidemiológicas y el proceso asistencial de los pacientes que fallecen durante las primeras 24 horas tras su llegada a urgencias. Método: Estudio unicéntrico descriptivo de todos los pacientes fallecidos durante las primeras 24 horas tras su llegada a urgencias durante el año 2009. Se compararon según el lugar del fallecimiento (urgencias o planta) el tipo de paciente (terminal o no) ys e analizó la calidad asistencial prestada. Resultados: Se produjeron 164 fallecimientos, 81 de ellos en hospitalización y 83 en urgencias(tasa de mortalidad 0,091%). La edad media de los pacientes fue de 78,4 ± 14,7años, el 54,9% fueron mujeres, el 85% tenía alguna comorbilidad importante y el índicede Karnofsky medio fue de 66,1 ± 23,7. El 24,7% de sujetos se encontraba en fase terminal de su enfermedad. En el 82,2% de los casos el fallecimiento fue previsible a la llegada del paciente a urgencias. Las principales causas de muerte fueron las enfermedades cerebrovasculares(17,3%), seguidas de las neumonías (16,7%) y las septicemias (13,6%). La ubicación de los pacientes se consideró adecuada en el 98,8% de casos. Recibieron tratamiento con analgésicos opiáceos o sedación con mayor frecuencia los pacientes en fase terminal (64,1 frente a 34,2%, p < 0,05). En el 97,1% de casos se informó a los familiares acerca del pronóstico del paciente, y en el 87% éste se encontraba acompañado. Conclusiones: Dada la creciente demanda asistencial de pacientes afectados de patologías terminales, el análisis de su proceso asistencial permite garantizar las medidas de confort para ellos, con el fin de maximizar la calidad percibida por los enfermos y sus familiares (AU)

Objective: To describe and analyze the clinical and epidemiologic characteristics of the care process of patients who died within 24 hours of arriving at emergency department. Methods: Descriptive single-centre study of patients who died in the first 24 hours of arrival at our emergency department in 2009.Results: A total of 164 deaths occurred; 84 patients died after admission to a ward and 83 were in the emergency department (mortality rate, 0.091%). The mean (SD) age of these patients was 78.4 (14.7) years; 54.9% were women and 85% had a significant comorbid condition. The mean Karnofsky index was 66.1 (23.7). The terminal stage of adisease had been reached by 24.7% of the patients, and death was foreseen on the patient’s arrival in the emergency department in 82.2%. The most frequent cause of death was cerebrovascular disease (17.3%), followed by pneumonia(16.7%) and septicemia (13.6%). Patients were admitted to an appropriate place in 98.8% of the cases. Treatment with opioid analgesics or sedation was most often provided for patients in a terminal phase (64.1% vs 34.2%, P<.05). Families were informed about the patient’s prognosis in 97.1% of the cases; 87% of the patients were accompanied by a relative. Conclusions: Given that the demand for care of patients in terminal phases of disease is growing, analysis of the care process will allow us to ensure that measures are implemented to make them and their families as comfortable as possible (AU)

[Imaging tests in acute abdominal pain]. / Pruebas de imagen en el dolor abdominal agudo.

Acute abdominal pain constitutes a diagnostic challenge for the physician. The list of diseases that can cause abdominal pain is very extensive. Some of these conditions may be serious and life-threatening. The medical history is fundamental for the judicious choice of the most suitable diagnostic tests. Plain abdominal x-ray has little diagnostic efficiency although it comprises the initial diagnostic test when perforation of a hollow viscus, intestinal obstruction or ingestion of a foreign body is suspected. Abdominal ultrasound is the test of choice in suspected biliary tract pathology, complicated renal colic and gynaecological disease. Abdominal computed axial tomography (CT) may be the most sensitive and specific imaging test for diagnosing most causes of abdominal pain but should be reserved for selected cases.

[Influence of the sex of the physician in the alerting reaction in blood pressure determination in the elderly. EPICARDIAN Working Group]. / Influencia del sexo del médico en la reacción de alerta ante la toma de la presión arterial en el anciano. Grupo de Trabajo EPICARDIAN.

BACKGROUND: Blood pressure measurements by a physician and to a lesser extent by a nurse often lead the patient to experience an alerting reaction associated with an increase in blood pressure. The main factor seems to be the interaction between the patient and the observer physicians, on average, record higher office blood pressure than nurses and non-physicians. There is no information about the influence of the physician's gender on alerting reaction. OBJECTIVE: To asses the influence of gender's doctor on alerting reaction in the elderly. METHODOLOGY: EPICARDIAN study is a cross-sectional survey of the civilian non-institutionalized elderly population in a health area, including an inhome interview (phase I, n = 1,200) and a clinical examination (phase II, a random sample n = 333). Three different blood pressure measurements were performed: conventional blood pressure was measured by trained nurses at the participant's home, and at the hospital by two physicians: a man (group A, n = 131, 46% men) and a women (group B, n = 152, 45% men). All subjects were informed by a nurse that they were going to be interviewed by a doctor. Twenty-four hour ambulatory blood pressure was recorded at 15 minute intervals, awake and sleep periods were defined based on daily activities. Alerting reaction was defined as the difference between means at home, office and awake period. RESULTS: Office blood pressures were distinctively higher than the awake average (15 mmHg for systolic blood pressure and 7 mmHg for diastolic respectively) in 83% of subjects. Differences between clinical and awake average blood pressure were significantly higher in females than in males (17 +/- 16 and 12 +/- 16 respectively, p < 0.0001) and increased, in both sexes with increasing age (p = 0.001) and clinic blood pressure values (p < 0.001). There were no sex, age, body mass index, casual home blood pressure and awake blood pressure period differences between groups A and B. Group A, interviewed by a man, showed an average of 10 mmHg more than group B, interviewed by a woman, on office alerting reaction (22 +/- 18/11 +/- 11 mmHg versus 12 +/- 16/3.6 +/- 10 mmHg systolic blood pressure/diastolic blood pressure alerting reaction, respectively p < 0.001 in both cases). Differences were similar when analizying men and women independently. CONCLUSION: Alerting reaction during blood pressure measurement in the elderly is higher when the observer is a male physician than when the physician is a female, independent of the patient's gender.

What happens to blood pressure when on-call?

This study was designed to compare the 24-h blood pressure profile of young physicians during on-call days with those obtained during a normal day, and to explore the factors related to blood pressure reactivity in a stress situation. The study was a self-comparison study in two environments (on-call and at home). The study population was 100 physicians, staff, and residents working in the emergency room. A previously validated ambulatory, automated, auscultatory blood pressure (BP) monitoring device (A&D Takeda 2420) was used. BP measurements were programmed to be taken every 15 min and three time periods were considered for analysis: the whole day, awake, and sleep periods. Systolic and diastolic BP behavior were described by their average and distributions. Within each considered phase (on-call, at home) the pressor response was defined as the difference in average blood pressure. Being on-call modified both systolic and diastolic ambulatory BP profiles. Both average BP values and BP load were significantly higher when subjects were on-call. Systolic blood pressure increased in 83% of subjects and 40% displayed a significant pressor response of 10 mm Hg or more. For diastolic blood pressure some increase was observed in 93% of subjects, and a significant pressor response of 10 mm Hg or greater in 23% of them. Age, sex, personality, and tobacco consumption were not associated with the pressor response. Familial history of hypertension and professional status were the most important determinants of the pressor response.

[Nocturnal fall in arterial blood pressure in normotensive subjects: individual characteristic or the effect of daily activity?]. / Caída nocturna de la presión arterial en normotensos: rasgo individual o efecto de la actividad diurna?

BACKGROUND: The interpretation of the absence of a nocturnal fall in blood pressure (BP) (non-dipper condition) and its possible prognostic value are not clear. One possible hypothesis to be analyzed is whether the condition of non-dipper is due or not to the daily activity. METHODS: Ninety-five doctors, 47 of whom were females, whose age ranged between 24 and 46 years participated in the study. Ambulatory monitoring BP were programmed to be randomly carried out on-call and on a day-off with measurements intervals of 15 min. Mean systolic BP (SBP), diastolic BP (DBP) and heart rate (HR) were considered as measurement parameters for every period: 24 h, awake and sleep. Sleep period was considered as one of no less than 2 hours, nocturnal BP fall was defined as the difference between awake and sleep means, and dipper condition as a systolic decrease greater than 10 mmHg and diastolic decrease greater than 5 mmHg. RESULTS: The mean nocturnal BP fall on the day-off was of 15% and 13% (SBP and DBP) and while on-call it was 18% and 15% respectively (p < 0.001). In absolute values the SBP decreased 21 +/- 10 mmHg and 18 +/- 10 mmHg and the DBP 11 +/- 6 mmHg and 10 +/- 5 mmHg, on-call and day off respectively (p < 0.001). The percentage of subjects with decrease lower than 10/5 mmHg was different in each of the two days (8% and 12%), however only one individual maintained the non-dipper condition in both period, although he reported many interruptions in the sleep. No association was established between the nocturnal BP fall and other variables (age, sex or family history of hypertension). CONCLUSION: The non-dipper condition is changeable and is related to the activity carried out by the subject while awake, as well as the quality of sleep. It does not seem to be associated with inherent variables of the individual such as family history of hypertension, age or sex.

[Liver disease in patients with human immunodeficiency virus infection. Study of 100 biopsies]. / Affección hepática en pacientes con infección por el virus de la immunodeficiencia humana. Estudio de cien biopsias.

Human immunodeficiency virus (HIV)-related liver disease is frequently diagnosed. We report a study about 100 liver biopsy samples (LB) in patients with HIV infection. The aim of the study has been to analyze the liver biopsy yield when a systemic disease (group A) or a chronic liver disease (group B) are suspected. Tuberculosis, all of them disseminated, was the most common finding in group A biopsy samples, and a 81% yield was obtained. Chronic active hepatitis was the most common finding group B, and profitability reached 90%. We conclude that LB is the elective method to diagnose systemic disease, in patients previously selected according to their clinical findings, and that final diagnoses and safe.

[Deep venous thrombosis of the upper extremity: a study of 10 cases]. / Trombosis venosa profunda del miembro superior: estudio de 10 casos.

BACKGROUND: Deep venous thrombosis (DVT) of upper limbs is less common than in lower limbs, although an increased prevalence has been observed in recent years. METHODS: The cases of DVT of upper limbs seen in an internal medicine service during a 24 month period were reviewed. Ten episodes out of overall 103 instances of DVT were identified (9.7%). The diagnosis was confirmed by colour echo-Doppler and/or phlebography. Subcutaneous calcium heparin was subcutaneously given at a dose of 2500 IU per 10 kg of body weight every 12 hours for 7 days, associated with oral anticoagulants given for a variable period in each case. RESULTS: The predisposing factors were: strenuous physical exercise (2 cases), oral contraceptives (2 cases), C-protein deficiency (1 case), parenteral drug abuse (PDA) (1 case), mediastinal mass (1 case), indwelling catheter (1 case) and absence of an apparent factor (2 cases). The colour echo-Doppler diagnosis was definitive in all cases where the study was carried out (8/10). The response to therapy was favourable in all cases. No case of pulmonary thromboembolism was found and post-phlebitic sequelae did not develop in the patients who could be followed up (6/10). CONCLUSIONS: The prevalence of deep venous thrombosis of upper limbs is increasing in recent years. The introduction of colour echo-Doppler is a very helpful noninvasive diagnostic procedure. Subcutaneous calcium heparin at the reported dose is a good therapeutic approach.

[Inadequate ADH secretion syndrome associated with acquired immunodeficiency syndrome]. / Síndrome de secreción inadecuada de ADH asociado a síndrome de inmunodeficiencia adquirida.

Within the numerous complications of AIDS, we want to point out the appearance of inadequate ADH secretion syndrome (IADHSS) in 9 out of; patients, which constitutes a higher percentage than in the general population. In all cases IADHSS was associated to lung or central nervous system pathology. In one patient, IADHSS preceded the appearance Pneumocystis carinii pneumonitis. Therefore, if hyponatremia is founding AIDS patients, the existence of adrenal pathology or IADHSS should be suspected.