Peripheral trauma treated in the pediatric emergency department: Descriptive study. / Traumatismos periféricos atendidos en el Servicio de Urgencias Pediátricas. Estudio descriptivo.

INTRODUCTION: Peripheral trauma is a very frequent cause of consultation in paediatric emergency departments but few studies have been published describing the characteristics of these patients. MATERIAL AND METHODS: We performed a retrospective descriptive study by reviewing computerised emergency department forms during January and February 2020. OBJECTIVE: To describe the characteristics of traumatic injuries in our area and to detect possible areas for improvement. RESULTS: A total of 714 peripheral trauma cases were attended, which represents 9.5% of the total consultations. A total of 52.7% were schoolchildren (6-11 years). The most frequent locations were the ankle (27.5%) and fingers (17.2%). Fracture was detected in 6.7% of cases. Radiographs were requested in 78.6% of the patients, with pathological findings in 9.6% of them. Half of the X-rays were requested due to ankle or finger trauma. Referral to traumatology was made in 16.4% of patients, mainly for elbow and knee trauma, and the most commonly used treatment was general measures (49%) and bandaging (29.4%). CONCLUSIONS: Peripheral trauma is very common and, in general, banal. A large number of X-rays are requested with a very low yield, so it seems necessary to establish new protocols to reduce the number of requests. Improving training in elbow and knee trauma could improve paediatricians' autonomy in dealing with these more complex injuries.

Epicardial pacemaker implantation and outcome in eight pet ferrets (Mustela putorius furo).

INTRODUCTION/OBJECTIVES: Minimal information exists regarding epicardial pacemaker (EP) implantation in pet ferrets (Mustela putorius furo). The objectives were to describe the indications, surgical technique, and outcome of EP implantation in ferrets for the treatment of advanced atrioventricular block (AVB). ANIMALS, MATERIALS, AND METHODS: Eight client-owned ferrets presenting to five veterinary referral centers. Signalment, physical exam findings, diagnostic tests, anesthesia protocols, surgical implantation techniques, postoperative treatment plans, and EP interrogations were reviewed. Intra- and postoperative, minor and major, and EP-related complications were established. Descriptive statistics were performed to report complication rates. Survival analyses were performed. RESULTS: All ferrets had advanced AVB: 3/8 had high-grade second-degree and 5/8 had third-degree. The primary clinical signs were collapse and weakness. Seven EP were implanted via a transdiaphragmatic approach and one via a left intercostal thoracotomy. Intraoperative complications occurred in 2/8 ferrets, both major. One ferret with severe comorbidities died during general anesthesia. Postoperative pacemaker-related complications were minor: inappropriate sinus beat sensing in 2/8 and occasional muscle fasciculations in 1/8. Two ferrets were alive at the time of manuscript submission, at 10 and 21 months postoperatively. The overall median survival time was 24 months. CONCLUSIONS: Implantation of EP was performed successfully in most ferrets for treatment of advanced AVB and was well tolerated. Ferrets with advanced AVB may experience resolution of clinical signs associated with their cardiac disease following EP implantation. Additional studies are warranted to investigate the effects of epicardial pacing on survival times in this species.

Atypical symptoms of gastro-esophageal reflux during pregnancy.

BACKGROUND: Pregnancy is associated with an increased incidence of heartburn. However, there is no information for other symptoms related to gastro-esophageal reflux (GOR). AIM: to assess the prevalence of atypical symptoms of GOR during pregnancy, and to examine its association with typical GOR symptoms. METHODS: we report data for 263 women with a pregnancy of less than 12 weeks. They were interviewed at the end of each trimester of pregnancy and at 1-year post-partum, using the Gastro Esophageal Reflux Questionnaire (GERQ). In the first interview, information about symptoms in the year before pregnancy was also collected with GERQ. RESULTS: women suffered atypical GOR symptoms during pregnancy more frequently than in the year before: non-cardiac chest pain (NCCP) (9.1 vs. 1.9%), dysphagia (12.6 vs. 2.3%), globus (33.1 vs. 4.6%), cough (26.6 vs. 6.8%), belching (66.2 vs. 19.4%) and hiccups (19.0 vs. 8.4%). Atypical GOR symptoms in pregnancy showed an association with suffering the same symptom before pregnancy and NCCP, globus, belching and hiccups with suffering typical GOR symptoms in the first trimester. CONCLUSIONS: Atypical GOR symptoms are highly prevalent in pregnancy, and are associated with atypical symptoms before pregnancy and with typical symptoms of GOR in the first trimester.

Onset and disappearance rates of gastroesophageal reflux symptoms in the Spanish population, and their impact on quality of life.

BACKGROUND: few studies have reported the onset and disappearance rates of gastroesophageal reflux symptoms (GERS) in the population. AIM: to assess the occurrence and disappearance rates of GERS in Spain, and their impact on health-related quality of life (HRQL). PARTICIPANTS AND METHODS: participants were selected at random from the general population of Madrid in age and sex strata. They were interviewed at home twice, 6 months apart. Heartburn, acid regurgitation and consultation were assessed with the gastroesophageal reflux questionnaire, and HRQL with the SF-36. RESULTS: 709 individuals were included, and 451 (63.6%) were re-interviewed 6 months later. Among the 325 individuals without GERS, 9 developed weekly symptoms (2.2% [95% CI: 0.8, 3.4%]); 2 (22%) consulted because of GERS. Among the 34 subjects reporting weekly GERS initially, 26 did not report them at 6-months. Onset of GERS was associated with worsening scores in the physical summary of SF-36 (delta = -6.6 [95% CI: -11.8, -1.42]), while disappearance with an improved score (delta = -3.0 [95% CI: 0.0, 5.9]). CONCLUSION: despite the lower prevalence of GERS in Spain, the occurrence rate is 2.2% in 6 months; however symptoms disappeared in more than half of subjects six months later. Developing GERS was associated with reduced HRQL, and their disappearance with improvement.

Onset and disappearance rates of gastroesophageal reflux symptoms in the Spanish population, and their impact on quality of life

Background: few studies have reported the onset and disappearancerates of gastroesophageal reflux symptoms (GERS) inthe population.Aim: to assess the occurrence and disappearance rates ofGERS in Spain, and their impact on health-related quality of life(HRQL).Participants and methods: participants were selected atrandom from the general population of Madrid in age and sexstrata. They were interviewed at home twice, 6 months apart. Heartburn,acid regurgitation and consultation were assessed withthe gastroesophageal reflux questionnaire, and HRQL with theSF-36.Results: 709 individuals were included, and 451 (63.6%)were re-interviewed 6 months later. Among the 325 individualswithout GERS, 9 developed weekly symptoms (2.2% [95% CI:0.8, 3.4%]); 2 (22%) consulted because of GERS. Among the 34subjects reporting weekly GERS initially, 26 did not report themat 6-months. Onset of GERS was associated with worseningscores in the physical summary of SF-36 (delta = -6.6 [95%CI: -11.8, -1.42]), while disappearance with an improved score(delta = -3.0 [95% CI: 0.0, 5.9]).Conclusion: despite the lower prevalence of GERS in Spain,the occurrence rate is 2.2% in 6 months; however symptoms disappearedin more than half of subjects six months later. DevelopingGERS was associated with reduced HRQL, and their disappearancewith improvement(AU)

[Spanish physicians point of view on irritable bowel syndrome (IBS). Results of a Delphi survey]. / Opinión de los médicos españoles sobre el síndrome de intestino irritable: resultados de un estudio utilizando el método Delphi.

INTRODUCTION: lack of evidence in most clinical situations regarding irritable bowel syndrome (IBS) enhances the importance of an expert s opinion, which will guide management and even the concept underlying the disease. OBJECTIVE: to delve into the knowledge and degree of agreement on main clinical skills for this syndrome among physicians involved in its management. MATERIAL AND METHOD: two rounds of a Delphi survey were conducted on 100 physicians: general practitioners (GPs) and gastroenterologists. The questionnaire evaluated agreement among participants in some aspects regarding the definition, diagnosis, and treatment of IBS. RESULTS: fifty-five percent of participants completed the two-round survey. Agreement was achieved regarding the definition of typical symptoms and red flags characterizing IBS. Although there was no consensus regarding the appropriate management of patients without alarm symptoms, the performance of a colonoscopy on any patient presenting red flags was suggested. Patients were thought to require a wider examination when older than 40. A well defined line of IBS treatment was not found, albeit most physicians tended to choose it depending on the main complaint. CONCLUSION: interviewed physicians showed adequate theoretical knowledge of IBS, but lack of uniformity on diagnosis and treatment approach reflects the controversial day-by-day management of this syndrome.

Opinión de los médicos españoles sobre el síndrome de intestino irritable: resultados de un estudio utilizando el método Delphi / Spanish physicians’ point of view on irritable bowel syndrome (IBS). Results of a Delphi survey

Introducción: el síndrome del intestino irritable (SII) es una patología controvertida, donde ante la escasez de evidencia científica las recomendaciones sobre su manejo clínico y su definición vienen determinadas por métodos de consenso de expertos. Objetivo: obtener la opinión de los médicos de nuestro país implicados en el manejo de pacientes con SII y conocer los puntos de acuerdo en las principales cuestiones clínicas que plantea. Material y métodos: se realizó un estudio Delphi a nivel nacional mediante dos envíos a 100 médicos de atención primaria y gastroenterólogos. El cuestionario incluía preguntas sobre el concepto, diagnóstico y tratamiento del SII, evaluando el grado de acuerdo entre los participantes. Resultados: el 55% de los encuestados completó los dos envíos. Se obtuvo acuerdo respecto a los síntomas que caracterizan al SII y los de alarma. No existió una actitud clara ante el paciente sin síntomas de alarma, pero sí acuerdo respecto a la realización de colonoscopia en su presencia. Se señaló la necesidad de realizar estudios complementarios en mayores de 40 años. En el tratamiento no encontramos una actitud uniforme, aunque parece existir una orientación diferente según el síntoma predominante. Conclusiones: los médicos participantes en el estudio demuestran a través de sus respuestas un buen conocimiento conceptual del SII, si bien las discrepancias observadas en las cuestiones sobre diagnóstico y tratamiento demuestran la complejidad y falta de uniformidad que existe en el manejo diario de este síndrome

Introduction: lack of evidence in most clinical situations regarding irritable bowel syndrome (IBS) enhances the importance of an expert’s opinion, which will guide management and even the concept underlying the disease. Objective: to delve into the knowledge and degree of agreement on main clinical skills for this syndrome among physicians involved in its management. Material and method: two rounds of a Delphi survey were conducted on 100 physicians: general practitioners (GPs) and gastroenterologists. The questionnaire evaluated agreement among participants in some aspects regarding the definition, diagnosis, and treatment of IBS. Results: fifty-five percent of participants completed the tworound survey. Agreement was achieved regarding the definition of typical symptoms and red flags characterizing IBS. Although there was no consensus regarding the appropriate management of patients without alarm symptoms, the performance of a colonoscopy on any patient presenting red flags was suggested. Patients were thought to require a wider examination when older than 40. A well defined line of IBS treatment was not found, albeit most physicians tended to choose it depending on the main complaint. Conclusion: interviewed physicians showed adequate theoretical knowledge of IBS, but lack of uniformity on diagnosis and treatment approach reflects the controversial day-by-day management of this syndrome

Which is the best distension protocol to study rectal sensitivity in the irritable bowel syndrome?

OBJECTIVE: To evaluate any differences in rectal distension perception between healthy subjects and patients with irritable bowel syndrome (IBS) according to an isobaric distension protocol (progressive or phasic). MATERIAL AND METHODS: 10 healthy subjects and 41 patients with IBS (Rome II criteria). Rectal distension was performed using a barostat connected to a 500 mL bag, and a progressive distension protocol (continuous distension at a rate of 0.36 mmHg/sec) was compared to phasic distension protocol (distensions for 60 sec with 4 mmHg increases separated by 0 mmHg pressures during 60 sec). Perception was evaluated using three descriptive scales of 7 categories each for perception type, intensity, and affectivity. Perception thresholds were assessed. RESULTS: No significant differences in any perception thresholds were found between control subjects and IBS patients using a progressive distension protocol. Differences in the perception of inconvenient distension and maximum tolerable distension were encountered with the phasic distension protocol. Uncomfortable distension thresholds below those of controls were found in 48.8% of patients with IBS when a phasic distension protocol was used, versus only 9.7% with a progressive protocol. CONCLUSION: Hypersensitivity in patients with IBS is mainly seen with the use of phasic distension isobaric protocols for affective negative perceptions.

Long-term outcome of patients with non-cardiac chest pain.

OBJECTIVE: To assess long-term outcome for patients with chest pain in our environment, to estimate direct resource use, and to evaluate the influence of patient views regarding pain origin on outcome. PATIENTS AND METHODS: All patients referred to our Department between 1994 and 1998 to undergo pH-metry as a result of chest pain were identified. Those detected were subjected to a structured direct interview on the telephone. RESULTS: 104 patients with a follow-up period (since pH-metry) of 3.76 years were evaluated. Thirty nine percent of patients were free from pain (37.5%), and one had died from a seemingly unrelated cause (1%), whereas the rest still suffered from pain. The mean number of visits per patient during the last year was 2.83 to their general practitioner, 1.04 to an specialist, and 0.99 to an Emergency Unit; hospitalisations were 0.26, and ICU admissions 0.09. Patients who trusted medical diagnoses showed better outcomes than those who did not trust or understand them, in association with lower resource use, particularly Emergency Unit use. CONCLUSION: Patients with chest pain had a favourable life prognosis, but 60% still suffer from pain after nearly 4 years of follow-up, which entails a relevant use of health-care resources. Trust in medical diagnosis seemingly influences outcome, and the use of diagnostic procedures to determine pain origin is thus likely beneficial for patient.

¿Cuál es el mejor protocolo de distensión para estudiar la sensibilidad rectal en el síndrome de intestino irritable? / Which is the best distension protocol to study rectal sensitivity in the irritable bo wel syndrome?

Objetivo: Evaluar si existen diferencias en la percepción a la distensión rectal entre sujetos sanos y pacientes con síndrome de intestino irritable (SII) según el protocolo de distensión isobárico utilizado (progresivo o fásico).Material y métodos: 10 sujetos sanos y 41 pacientes con SII (criterios de Roma II). Las distensiones rectales se realizaron con un barostato conectado a una bolsa de 500 ml, comparándose un protocolo de distensión progresiva (distensión continua a un ritmo de 0,36 mmHg/seg) con un protocolo de distensión fásica (distensiones de 60 seg de duración a incrementos de 4 mmHg separadas por 60 seg de presión 0 mmHg). La percepción se evaluó con tres escalas descriptivas de 7 categorías cada una para el tipo, la intensidad y la afectividad de la percepción. Se evaluaron los umbrales perceptivos. Resultados: no se encontraron diferencias significativas entre controles y SII en ningún umbral de percepción con el protocolo de distensión progresiva. Con el protocolo de distensión fásica existieron diferencias en la percepción de distensión molesta y la máxima tolerable. El 48,8 por ciento de los pacientes con SII presentaban un umbral de distensión molesta por debajo de los controles con el protocolo de distensión fásico mientras sólo el 9,7 por ciento con el protocolo progresivo. Conclusión: la hipersensibilidad que presentan los pacientes con SII se observa fundamentalmente con protocolos isobáricos de distensión fásica para percepciones afectivamente negativas (AU)

Laringitis posterior: ¿dónde estamos? / Posterior laryngitis: where are we?

No disponible

Evolución a largo plazo del dolor torácico no cardiaco / Long-term outcome of patients with non-cardiac chest pain

Objetivo: evaluar la evolución a largo plazo de los pacientes con dolor torácico en nuestro medio, estimar el consumo directo de recursos y evaluar la influencia de la opinión del paciente sobre el origen del dolor en la evolución. Pacientes y métodos: se identificó a todos los pacientes remitidos a nuestro Servicio para la realización de pHmetría por dolor torácico entre 1994 y 1998, realizándose una entrevista estructurada telefónica directa a los que se logró contactar. Resultados: se evaluaron 104 pacientes con un periodo de seguimiento (desde la realización de pHmetría) de 3,76 años. El 39 por ciento de los pacientes no presentaban dolor (37,5 por ciento) y 1 había fallecido de causa aparentemente no relacionada (1 por ciento), persistiendo el resto con dolor . El número medio por paciente de consultas realizadas a su médico de Atención Primaria en el último año fue de 2,83, al médico Especialista 1,04, al Servicio de Urgencia 0,99, ingresos hospitalarios 0,26 e ingresos en UCI 0,09. Los pacientes que confiaban en el diagnóstico del médico mostraba una evolución mejor comparado con los que no confiaban y los que no comprendían el diagnóstico, asociándose con un menor recursos de recursos, especialmente visitas a urgencia. Conclusión: los pacientes con dolor torácico presentan un buen pronóstico vital aunque el 60 por ciento continua presentando dolor después de casi 4 años de seguimiento, conllevando un importante consumo de recursos sanitarios. La confianza en el diagnóstico médico parece influir sobre la evolución por lo que perseguir con estudios diagnósticos el origen del dolor es probablemente beneficioso para el paciente (AU)

Punto: Laringitis péptica: ¿por qué? / No disponible

No disponible

Does progesterone fluctuation across the menstrual cycle predispose to gastroesophageal reflux?

OBJECTIVE: Gastroesophageal reflux (GER) occurs in 30-50% of all pregnancies. The progressive rise in plasma progesterone has been suggested as a possible mediator of GER during pregnancy. It is not known whether progesterone, at physiological concentrations, has an effect on acid contact time. We sought to evaluate the relationship between progesterone concentrations, lower esophageal sphincter pressure (LESP), and acid contact time across the normal menstrual cycle. METHODS: LESP, 24-h ambulatory esophageal pH monitoring, and serum progesterone levels were determined in 19 healthy women known to have normal menstrual cycles. All tests were performed during the follicular phase (days 2-7) and the luteal phase (days 22-28) of one or two consecutive menstrual cycles. RESULTS: Despite marked oscillations in progesterone levels between the follicular phase (0.37 +/- 0.3 ng/ml) and luteal phase (4.64 +/- 2.92 ng/ml) we observed no significant differences in LESP (29.82 +/- 9.49 vs 30.45 +/- 8.56 mm Hg) or 24-h ambulatory pH levels (pH < 4) in total time (3.04 +/- 0.3% vs 3.18 +/- 2.51%), upright time (4.41 +/- 3.54% vs 4.18 +/- 3.36%), or supine time (0.77 +/- 1.32% vs 1.42 +/- 2.18%). CONCLUSIONS: The fluctuations in progesterone levels across the normal menstrual cycle have no significant impact on LESP and 24-h ambulatory pH parameters. Progesterone, at physiological concentrations, does not predispose to GER in healthy menstruating women.

[Intermittent obstructive jaundice as a form of presentation of duodenal diverticulum]. / Ictericia obstructiva intermitente como forma de presentación de un divertículo duodenal.

We report the case of a previously well 89-years-old-healthy man who presented at least four episodes of intermittent obstructive jaundice during the eight months prior to admission in our Hospital. Studies revealed a duodenal diverticulum arising near of the ampulla of Vater. We believed the diverticulum was responsible for the intermittent obstructive jaundice and we performed a choledochoduodenostomy. He had no postoperative complications and was discharged from the hospital asymptomatic. This case documents an uncommon presentation of this disease generally asymptomatic with intermittent obstructive jaundice episodes.

Ictericia obstructiva intermitente como forma de presentación de un divertículo duodenal / Intermittent obstructive jaundice secondary to duodenal diverticulum

Se presenta el caso de un varón de 89 años sin antecedentes de interés que presentó al menos cuatro episodios de ictericia obstructiva autolimitada consecutivos en el trascurso de ocho meses, requiriendo ingreso hospitalario en los dos últimos, objetivándose finalmente como causa de los mismos la presencia de un divertículo duodenal periampular por lo que fue intervenido quirúrgicamente, lo que resolvió de forma definitiva el cuadro. Se considera de interés esta forma inusual de presentación de esta patología generalmente asintomática, con episodios intermitentes de ictericia obstructiva (AU)

[Leiomyoma-dependent ileal invagination as a cause of intermittent intestinal obstruction]. / Invaginación ileal dependiente de leiomioma como causa de obstrucción intestinal intermitente.

We report the case of a 35-years-old-woman with history of abdominal surgery who presented several episodes of intermittent intestinal obstruction. Postoperative adhesions were suspected; laparoscopy surgery was made and uterine and anexial inflammation was observed. She was discharge with the diagnosis of inflammatory pelvic disease. Posteriorly, she was admitted with a new episode of intestinal obstruction. At laparotomy, intestinal intussusception was founded due to the presence of intestinal leiomyoma. We stress the relevance of two possible etiologies of intestinal obstruction; the coexistence of them difficult the diagnosis. Epidemiology, clinical presentation and diagnosis of leiomyomas of small intestine were reviewed.