Relación entre la utilización de recursos sanitarios y aspectos socioeconómicos en Atención Primaria / Relationship between the use of health resources and psychosocioeconomic aspects in Primary Care

Introducción: estudiar la influencia de los factores socioeconómicos y psicológicos familiares en la demanda y utilización de recursos sanitarios en las consultas pediátricas de Atención Primaria (AP). Material y métodos: estudio descriptivo observacional realizado mediante cuestionarios recogidos, durante un periodo de 1 año a familias de niños entre 1 mes y 14 años de edad pertenecientes a 2 consultas urbanas de AP de Madrid. Se analizaron datos crudos, comparaciones entre grupos y análisis multivariante. Resultados: se analizaron 434 cuestionarios. El número de consultas totales fue mayor en los pacientes de menor edad (p = 0,001) y en aquellos cuyos padres presentaban elevado nivel de ansiedad (p = 0,001). Las familias con todos sus miembros en paro presentaron niveles de ansiedad (odds ratio [OR]: 5,85; intervalo de confianza del 95% [IC 95]: 2,56 a 13,34; p <0,0001) y depresión (OR: 6,25; IC 95: 2,64 a 14,76; p <0,0001) significativamente superiores al resto. La realización de pruebas de laboratorio fue superior en los niños con enfermedad crónica (OR: 3,84; IC 95: 2,09 a 7,07; p <0,0001) y en aquellos con un nivel de ansiedad elevado en los padres (OR: 2,78; IC 95: 1,46 a 5,28); p = 0,02). La toma de fármacos fue superior en los niños con enfermedad crónica (OR: 3,15; IC 95: 1,60 a 6,19; p = 0,001) y menor en los niños de más edad (OR: 0,93; IC 95: 0,87 a 0,98; p = 0,014). Conclusiones: la frecuentación y el consumo de fármacos en general y antibióticos en particular, así como la solicitud de pruebas diagnósticas de laboratorio e imagen están directamente relacionados con el nivel elevado de ansiedad o depresión en los padres y con la presencia de enfermedad crónica en los niños e inversamente con la edad de los mismos. Sería recomendable la detección e intervención en los casos de elevada ansiedad parental para intentar reducir el consumo de recursos sanitarios (AU)

Introduction: the aim of our study was to analyse the influence of family socioeconomic and psychological factors on the demand and use of health resources in paediatric consultations in Primary Care.Methods: descriptive observational study carried out using questionnaires collected over a period of 1 year. Questionnaires were collected from children between 1 month and 14 years old, belonging to 2 urban Primary Care clinics in Madrid. The raw data was analysed, and comparisons between groups and multivariate analysis were performed.Results: we compared 434 questionnaires. The number of total consultations was higher in younger patients (p = 0.001) and in those whose parents presented high levels of anxiety (p = 0.001). Families with all their members in unemployed presented anxiety (OR: 5.85; IC 95: 2.567-13.341; p <0.0001) and depression (OR: 6.250; IC 95: 2.647-14.760; p <0.0001) levels higher than the rest. Laboratory and imaging test were higher in children with chronic disease (OR: 3.84; IC 95: 2.09-7.07; p <0.0001) and high level of anxiety in parents (OR: 2.78; IC 95: 1.46-5.28; p = 0.02). Drugs use was higher in children with chronic disease (OR: 3.15; IC 95: 1.60-6.19; p = 0.001) and lower in older children (OR: 0.927; IC 95: 0.87-0.98; p = 0.014).Conclusions: hyper-attendance and drug consumption in general and antibiotics in particular, as well as the request for imaging and laboratory test, is directly related to the high level of anxiety in the parents and the presence of chronic disease in children and inversely with the age. It would be advisable to detect and, if possible, intervene in cases of high parental anxiety in order to try to reduce the consumption of health resources. (AU)

Estado del conocimiento sobre el Soporte Vital Avanzado Enfermero en España según la red social Twitter / State of the art about the Advanced Life Support Nurse in Spain according to the social media Twitter

Objetivo: Explorar la información existente sobre el Soporte Vital Avanzado Enfermero (SVAE) en Twitter. Metodología: Se realizó un estudio, de naturaleza documental, basado en una revisión métrica mediante una búsqueda sistemática de información sobre el SVAE en Twitter desde 31/01/10 al 7/03/20. Se analizaron tuits y usuarios empleando indicadores métricos. Resultados principales: Se analizaron 215 tuits. Año más productivo: 2019 con 83 tuits. De los 76 usuarios que publican sobre el SVAE, el 75% son hombres, mayormente de Madrid y enfermeros. Tema de más auge: Difusión del SVAE entre los profesionales de la salud (27%). Tema más divulgado y de repercusión: Intervenciones asistenciales del SVAE. Dicho recurso se observa en 12 CCAA. Conclusión principal: La red social Twitter muestra el SVAE como un recurso asistencial implantado en numerosas CCAA, del que se dispone una información creciente y complementaria a las bases de datos. Dicha información procede, principalmente, de eventos científicos, aportando valor y conocimientos sobre distintos aspectos del SVAE y permitiendo su debate entre profesionales del ámbito. (AU)

Objective: Exploring the current information about Advanced Life Support Nurse (SVAE) on Twitter. Methods: Metric review through a systematic search of SVAE information on Twitter from 31/01/10 to 07/03/20. It was analyzed tweets and users through the use of metric indicators. Results: 215 tweets were analyzed. Most productive year: 2019 with 83 tweets. From the 76 users who publish about SVAE, 75% were men, mostly from Madrid and nurses. Most popular topic: The spread of SVAE among health professionals (27%). The most widely disseminated topic and with repercussions: healthcare interventions of the SVAE. This resource can be observed in 12 Autonomous Communities. Conclusions: The SVAE is a healthcare resource implemented in many Autonomous Communities of Spain, with increasing information on Twitter, complementary to databases. Much of this information comes from scientific events, providing value and knowledge about different aspects of SVAE and allowing discussion among professionals in the field. (AU)

Impacto de la contaminación ambiental en los ingresos hospitalarios pediátricos: estudio ecológico / Impact of environmental pollution on paediatric hospital admissions: an ecological study

Objetivo: estudiar la relación existente entre los niveles de contaminantes atmosféricos y los ingresos hospitalarios pediátricos totales y por patología respiratoria en particular. Pacientes y métodos: estudio ecológico en el cual la variable dependiente analizada han sido los ingresos pediátricos generales y aquellos por patología respiratoria, concretamente neumonías, crisis asmáticas y bronquiolitis, en un hospital del centro de Madrid durante seis años (2012-2017). Como variables independientes se estudiaron los valores promedio de contaminantes ambientales registrados en la ciudad de Madrid. Se calcularon coeficientes de correlación y regresión lineal múltiple. Se comparó el promedio de ingresos cuando los valores de dióxido de nitrógeno (NO2) eran superiores e inferiores a 40 µg/m3. Resultados: durante el periodo de tiempo estudiado se registraron 10 512 ingresos en Pediatría general, 5328 (50,68%) causados por procesos respiratorios. Se encontró una correlación entre los niveles de NO2, CO, benceno y los ingresos hospitalarios totales y respiratorios en todos los casos con un valor de p <0,0001. En la regresión lineal múltiple los ingresos totales se relacionaron con los niveles de NO2 positiva y negativamente con la temperatura, en relación con los ingresos respiratorios se incrementan con los niveles de NO2 y benceno y disminuyen con la temperatura. Se calculó que si los niveles de NO2 no hubieran superado en ningún mes los niveles de 40 µg/m3 se podrían haber evitado el 8,37% (IC 95: 7,77 a 8,98) de los ingresos totales y el 6,73% (IC 95: 6 a 7,52) de los ingresos respiratorios. Conclusiones: se encontró una relación entre los ingresos totales y por enfermedad respiratoria en la infancia y los niveles de contaminantes atmosféricos, especialmente NO2. La mejora de la calidad del aire podría evitar un porcentaje significativo de ingresos pediátricos y propiciarla debería ser tarea prioritaria para los pediatras

Objective: to assess the association between levels of airborne pollutants and paediatric hospital admissions, overall and due to respiratory problems. Patients and methods: we conducted an ecological study in which the dependent variables were the number of total paediatric hospital admissions and the number of paediatric admissions due to respiratory problems, specifically pneumonia, asthma exacerbations and bronchiolitis, in a hospital located in the centre of Madrid over a period of 6 years (2012-2017). The independent variables were the mean levels of air pollutants recorded in the city of Madrid. We calculated correlation coefficients and fit multiple linear regression models. We compared the average number of admissions when the levels of nitrogen (NO2) were above and below 40 µg/m3. Results: in the period under study, there were 10 512 admissions to the general paediatrics ward, of which 5328 (50.68%) were due to respiratory problems. We found a correlation between the levels of NO2, CO, and benzene and the number of overall admissions and respiratory admissions, in every instance with a p-value of less than 0.0001. The multiple linear regression analysis revealed that the number of overall admissions was associated with NO2 levels (positively) and temperature (negatively), while respiratory admissions were associated to NO2 and benzene levels (positively) and temperature (negatively). We estimated that if the levels of NO2 had stayed below 40 µg/m3 throughout the study period, 8.37% (95 CI: 7.77 to 8.98) of total admissions and 6.73% (95 CI: 6 to 7.52) of respiratory admissions could have been avoided. Conclusions: we found an association between the number of admissions, overall and for respiratory causes, in the paediatric age group and the levels of air pollutants, especially NO2. Improving air quality could prevent a significant proportion of paediatric hospital admissions, and promoting this change should be a priority for paediatricians

Aspectos psicosociales relacionados con la hiperfrecuentación en las consultas pediátricas de atención primaria / Psychosocial aspects associated with excessive attendance in primary care paediatric clinics

OBJETIVO: La hiperfrecuentación es un problema relevante en las consultas pediátricas de atención primaria, por lo que el objetivo de nuestro estudio ha sido analizar el nivel de frecuentación en dichas consultas y su relación con determinados aspectos psicosociales de las familias asignadas a las mismas. PACIENTES Y MÉTODOS: Estudio descriptivo observacional realizado mediante cuestionarios recogidos durante un periodo de 6 meses y registrando la frecuentación de los 6meses previos. Se han completado 346 encuestas de niños entre 6 meses y 13 años de edad pertenecientes a dos consultas urbanas de atención primaria de Madrid. Se analizaron datos crudos, comparaciones entre grupos y análisis multivariante. RESULTADOS: El promedio de consultas en los últimos 6meses, del total de incluidos en el estudio, fue de 3,06 en el centro de salud y de 0,77 consultas en urgencias. Se consideró hiperfrecuentadores a los que habían acudido 6 o más veces al centro de salud en este periodo (> p90), que fueron 33 niños (9,53%). En el análisis multivariante, las variables relacionadas con ser hiperfrecuentador en las consultas del centro de salud fueron la presencia de elevado nivel de ansiedad en los padres (OR = 5,50; IC 95%: 2,49-12,17; p < 0,0001) y la edad de los niños (OR = 0,73; IC95%: 0,58-0,91; p = 0,005). El modelo presentó un área bajo la curva de 0,761 (IC 95%: 0,678-0,945; p < 0,0001). CONCLUSIONES: La frecuentación en las consultas pediátricas de atención primaria está directamente relacionada con el nivel elevado de ansiedad de los padres e inversamente con la edad de los niños. Sería recomendable detectar y a ser posible intervenir en los casos de elevada ansiedad parental para así intentar reducir la hiperfrecuentación asistencial

OBJECTIVE: Hyper-attendance is a significant problem in paediatric Primary Care clinics. The aim of our study was to analyse the level of attendance in these clinics and its relationship with certain psychosocial aspects of the families attending them. PATIENTS AND METHODS: Observational descriptive study was conducted using questionnaires collected during a period of 6 months, as well as recording the frequency of attendance in the previous 6months. A total of 346 questionnaires of children between 6months and 13 years of age belonging to 2 urban Primary Care clinics in Madrid were completed. The raw data was analysed, and comparisons between groups and multivariate analysis were performed. RESULTS: The mean number of consultations in the last 6 months, of the total included in the study, was 3.06 in the Primary Care centre, and 0.77 in the emergency services. It was considered over-frequent for those who had attended the Primary Care health centre 6 or more times in this period (> p90), of which there were 33 children (9.53%). In the multivariate analysis, the variables related to being frequent users of Primary Care clinics were: the presence of high level of anxiety in the parents (OR = 5.50; 95% CI: 2.49-12.17, P < .0001), and the age of the children (OR = 0.73; 95% CI: 0.58-0.91, P = .005). The model presented an area under the curve of 0.761 (95% CI: 0.678-0.945, P < .0001). CONCLUSIONS: The frequency of visits in paediatric Primary Care clinics is directly related to the high level of anxiety of the parents, and inversely to the age of the children. It would be advisable to detect and, if possible, intervene in cases of high parental anxiety in order to try to reduce the over-frequency in the paediatric primary health care

[Psychosocial aspects associated with excessive attendance in primary care paediatric clinics]. / Aspectos psicosociales relacionados con la hiperfrecuentación en las consultas pediátricas de atención primaria.

OBJECTIVE: Hyper-attendance is a significant problem in paediatric Primary Care clinics. The aim of our study was to analyse the level of attendance in these clinics and its relationship with certain psychosocial aspects of the families attending them. PATIENTS AND METHODS: Observational descriptive study was conducted using questionnaires collected during a period of 6months, as well as recording the frequency of attendance in the previous 6months. A total of 346 questionnaires of children between 6months and 13years of age belonging to 2 urban Primary Care clinics in Madrid were completed. The raw data was analysed, and comparisons between groups and multivariate analysis were performed. RESULTS: The mean number of consultations in the last 6months, of the total included in the study, was 3.06 in the Primary Care centre, and 0.77 in the emergency services. It was considered over-frequent for those who had attended the Primary Care health centre 6 or more times in this period (>p90), of which there were 33 children (9.53%). In the multivariate analysis, the variables related to being frequent users of Primary Care clinics were: the presence of high level of anxiety in the parents (OR=5.50; 95%CI: 2.49-12.17, P<.0001), and the age of the children (OR=0.73; 95%CI: 0.58-0.91, P=.005). The model presented an area under the curve of 0.761 (95%CI: 0.678-0.945, P<.0001). CONCLUSIONS: The frequency of visits in paediatric Primary Care clinics is directly related to the high level of anxiety of the parents, and inversely to the age of the children. It would be advisable to detect and, if possible, intervene in cases of high parental anxiety in order to try to reduce the over-frequency in the paediatric primary health care.

Impacto de la contaminación ambiental en las consultas pediátricas de Atención Primaria: estudio ecológico / Impact of air pollution in paediatric consultations in Primary Health Care: Ecological study

OBJETIVO: Estudiar la relación existente entre los niveles de contaminantes ambientales y la demanda por enfermedad respiratoria en las consultas pediátricas de Atención Primaria. PACIENTES Y MÉTODOS: Estudio ecológico en el que la variable dependiente analizada ha sido la demanda en las consultas pediátricas de un centro de salud urbano de Madrid durante 3 años (2013-2015) por bronquiolitis, episodios de broncoespasmo y procesos respiratorios de vías altas. Como variables independientes se estudiaron los valores de contaminación ambiental. Se calcularon coeficientes de correlación y regresión lineal múltiple. Se comparó el promedio de consultas cuando los valores de dióxido de nitrógeno (NO2) eran superiores e inferiores a 40 mig/m3. RESULTADOS: Durante el periodo de tiempo estudiado hubo un total de 52.322 consultas pediátricas en el centro de salud, de las cuales 6.473 (12,37%) lo fueron por procesos respiratorios. Se encontró correlación positiva entre los niveles de SO2, CO, NO2, NOx, benceno y el número de consultas por procesos respiratorios y negativa con la temperatura y el O3. El número de consultas por enfermedad respiratoria fue significativamente mayor cuando los niveles de NO2 superaban los 40 mig/m3. En la regresión lineal múltiple (p < 0,0001) solo se mantuvo la relación positiva de las consultas con los niveles de NO2 (3,630; IC 95%: 0,691-6,570) y negativa con la temperatura (-5,957; IC 95%: -8,665 a -3,248). CONCLUSIONES: La contaminación ambiental por NO2 está relacionada con el aumento de la enfermedad respiratoria en la infancia. Los pediatras deberíamos contribuir a propiciar la mejora de la calidad del aire como una importante medida preventiva

OBJECTIVE: To study the correlation between the levels of environmental pollutants and the number of paediatric consultations related to respiratory disease in Primary Health Care. PATIENTS AND METHODS: An ecological study is performed, in which the dependent variable analysed was the number of paediatric consultations in an urban Primary Health Care centre in Madrid over a 3 year period (2013-2015), and specifically the consultations related to bronchiolitis, recurrent bronchospasm, and upper respiratory diseases. The independent variables analysed were the levels of environmental pollutants. Coefficients of correlation and multiple lineal regressions were calculated. An analysis has been carried out comparing the average of paediatric consultations when the levels of nitrogen dioxide (NO2) were higher and lower than 40 mig/m3. RESULTS: During the period of the study, there were a total of 52,322 paediatric consultations in the health centre, of which 6,473 (12.37%) were related to respiratory diseases. A positive correlation was found between SO2, CO, NOx and NO2 and benzene levels and paediatric consultations related to respiratory diseases, and a negative correlation with temperature. The number of consultations was significantly higher when NO2 levels exceeded 40 mig/m3. In the multiple lineal regression (P=.0001), the correlation was only positive between consultations and NO2 levels (3.630, 95% CI: 0.691-6.570), and negative with temperature (-5,957, 95% CI: -8.665 to -3.248). CONCLUSIONS: NO2 environmental pollution is related to an increase in respiratory diseases in children. Paediatricians should contribute to promote an improvement in urban air quality as a significant preventive measure

[Impact of air pollution in paediatric consultations in Primary Health Care: Ecological study]. / Impacto de la contaminación ambiental en las consultas pediátricas de Atención Primaria: estudio ecológico.

OBJECTIVE: To study the correlation between the levels of environmental pollutants and the number of paediatric consultations related to respiratory disease in Primary Health Care. PATIENTS AND METHODS: An ecological study is performed, in which the dependent variable analysed was the number of paediatric consultations in an urban Primary Health Care centre in Madrid over a 3 year period (2013-2015), and specifically the consultations related to bronchiolitis, recurrent bronchospasm, and upper respiratory diseases. The independent variables analysed were the levels of environmental pollutants. Coefficients of correlation and multiple lineal regressions were calculated. An analysis has been carried out comparing the average of paediatric consultations when the levels of nitrogen dioxide (NO2) were higher and lower than 40µg/m3. RESULTS: During the period of the study, there were a total of 52,322 paediatric consultations in the health centre, of which 6,473 (12.37%) were related to respiratory diseases. A positive correlation was found between SO2, CO, NOx and NO2 and benzene levels and paediatric consultations related to respiratory diseases, and a negative correlation with temperature. The number of consultations was significantly higher when NO2 levels exceeded 40µg/m3. In the multiple lineal regression (P=.0001), the correlation was only positive between consultations and NO2 levels (3.630, 95% CI: 0.691-6.570), and negative with temperature (-5,957, 95% CI: -8.665 to -3.248). CONCLUSIONS: NO2 environmental pollution is related to an increase in respiratory diseases in children. Paediatricians should contribute to promote an improvement in urban air quality as a significant preventive measure.

Sueroterapia y riesgo de hiponatremia iatrogénica en niños hospitalizados con gastroenteritis aguda: estudio prospectivo / Fluid therapy and iatrogenic hyponatraemia risk in children hospitalised with acute gastroenteritis: prospective study

Objetivo: Determinar si la utilización de sueros hipotónicos supone un riesgo en la aparición de hiponatremia iatrogénica en los niños hospitalizados por gastroenteritis aguda (GEA). Pacientes y método: Estudio prospectivo realizado con 205 pacientes de edades comprendidas entre 1 y 28 meses e ingresados con diagnóstico de deshidratación leve o moderada por GEA para recibir sueroterapia en la sección de lactantes de un hospital pediátrico de Madrid (España). El grado de deshidratación inicial se estimó con mediciones clínicas estándar. El suero administrado fue glucosalino 0,3 % en 198 casos y en los 7 casos restantes, todos con hipernatremia inicial, se administró suero glucohiposalino 0,2 %. Se analizó la respuesta a los líquidos intravenosos según si el niño se hallaba normo, hipo o hipernatrémico antes de iniciar el tratamiento. Las cifras de sodio en sangre y la excreción fraccional de sodio (EFNa) se consideraron como medidas de resultado. Resultados: Los 205 pacientes incluidos en el estudio se distribuyeron en tres grupos según el resultado inicial de la natremia. En 37 casos se detectó hiponatremia (18,04 %), en 133 niños isonatremia (64,87 %) y en 35 niños hipernatremia (17,07 %). Después de administrar soluciones hipotónicas encontramos en todos los grupos diferencia significativa entre el sodio sérico inicial y el final; en el grupo con hiponatremia el sodio subió y en los grupos con iso e hipernatremia el sodio descendió ligeramente. Se evidenció correlación significativa entre la EFNa y la evolución de la natremia (Na sérico inicial - Na sérico final). No se detectó ningún caso de hiponatremia posinfusión y tampoco se encontró correlación entre el agua libre administrada y la evolución de la natremia. Conclusiones: En lactantes con funcionamiento renal normal no se ha encontrado hiponatremia como resultado de la administración de sueros hiposalinos intravenosos, hallándose diferencias significativas en la EFNa que indican el ajuste renal de la natremia (AU)

Objective: The purpose of this study is to analyse whether the use of hypotonic fluids increases the risk of iatrogenic hyponatraemia in children hospitalised with acute gastroenteritis (AGE). Patients and methods: Prospective study carried out on 205 patients with ages ranging from 1 to 28 months and admitted with a diagnosis of mild or moderate dehydration due to AGE and treated with intravenous hypotonic fluids in a paediatric department in Madrid (Spain). The degree of dehydration at presentation was estimated using standard clinical measures. 198 children received 0.3 % glucosaline solution and in 7 patients, with baseline hypernatraemia, 0.2 % gluco-hyposaline solution was administered. We analysed the results according to whether children were hyponatraemic, normonatraemic or hypernatraemic at presentation. The blood and urine samples were analysed and the concentration of sodium and fractional sodium excretion (EFNa) before and after intervention were considered as outcome measures. Results: The 205 patients included in the study were distributed in 3 groups according to the baseline natraemia results. In 37 cases we detected hyponatraemia (18.04%), in 133 cases isonatraemia (64.87%) and in 35 children hypernatraemia (17.07%). After administering hypotonic fluids we detected a significant difference between initial and final natraemia in all groups; in the group with hyponatraemia, sodium increased and in the groups with iso and hypernatraemia, sodium slightly decreased. A significant correlation between the EFNa and the evolution of natraemia was found. No cases of hyponatraemia post-infusion were seen and there was no correlation between free water administered and natraemia evolution. Conclusions: Results show that the use of hypotonic fluids does not increase the risk of hospital acquired hyponatraemia in hospitalised children with normal renal function. Our children with gastroenteritis did not develop hyponatraemia even though they were all treated with hypotonic intravenous solutions (AU)

Fluid therapy and iatrogenic hyponatraemia risk in children hospitalised with acute gastroenteritis: prospective study.

OBJECTIVE: The purpose of this study is to analyse whether the use of hypotonic fluids increases the risk of iatrogenic hyponatraemia in children hospitalised with acute gastroenteritis (AGE). PATIENTS AND METHODS: Prospective study carried out on 205 patients with ages ranging from 1 to 28 months and admitted with a diagnosis of mild or moderate dehydration due to AGE and treated with intravenous hypotonic fluids in a paediatric department in Madrid (Spain). The degree of dehydration at presentation was estimated using standard clinical measures. 198 children received 0.3 % glucosaline solution and in 7 patients, with baseline hypernatraemia, 0.2 % gluco-hyposaline solution was administered. We analysed the results according to whether children were hyponatraemic, normonatraemic or hypernatraemic at presentation. The blood and urine samples were analysed and the concentration of sodium and fractional sodium excretion (EFNa) before and after intervention were considered as outcome measures. RESULTS: The 205 patients included in the study were distributed in 3 groups according to the baseline natraemia results. In 37 cases we detected hyponatraemia (18.04%), in 133 cases isonatraemia (64.87%) and in 35 children hypernatraemia (17.07%). After administering hypotonic fluids we detected a significant difference between initial and final natraemia in all groups; in the group with hyponatraemia, sodium increased and in the groups with iso and hypernatraemia, sodium slightly decreased. A significant correlation between the EFNa and the evolution of natraemia was found. No cases of hyponatraemia post-infusion were seen and there was no correlation between free water administered and natraemia evolution. CONCLUSIONS: RESULTS show that the use of hypotonic fluids does not increase the risk of hospital acquired hyponatraemia in hospitalised children with normal renal function. Our children with gastroenteritis did not develop hyponatraemia even though they were all treated with hypotonic intravenous solutions.