Mejora en el manejo de la sospecha del síndrome aórtico agudo en urgencias mediante un algoritmo clínico y el estudio de factores predictivos / Improvement in the management of suspected acute aortic syndrome in the emergency room through a clinical algorithm and study of predictive factors

Antecedentes y objetivo: El síndrome aórtico agudo (SAA) es poco frecuente y difícil de diagnosticar, con una gran variabilidad en su cuadro clínico inicial. Los objetivos son: 1) desarrollar un algoritmo informático, o un sistema de apoyo a las decisiones clínicas (SADC), para el manejo y la solicitud de estudios de diagnóstico por imagen en el servicio de Urgencias, en concreto de una tomografía computarizada (TC) de la aorta, ante la sospecha de SAA, 2) determinar el efecto de la implantación de este sistema, y 3) determinar los factores asociados a un diagnóstico radiológico positivo que mejoren la capacidad predictiva de los hallazgos de la TC de aorta. Material y métodos: Tras desarrollar e implementar un algoritmo basado en la evidencia, se estudiaron casos de sospecha de SAA. Se utilizó el test de la χ2 para analizar la asociación entre las variables incluidas en el algoritmo y el diagnóstico radiológico, con 3 categorías: sin hallazgos relevantes, positivo para SAA y diagnósticos alternativos. Resultados: Se identificaron 130 solicitudes; 19 (14,6%) tenían SAA y 34 (26,2%) tenían otra patología aguda. De las 19 con SAA, 15 habían sido estratificadas como de alto riesgo y 4 como de riesgo intermedio. La probabilidad de SAA era 3,4 veces mayor en los pacientes con aneurisma aórtico conocido (p=0,021, IC del 95%: 1,2-9,6) y 5,1 veces mayor en los pacientes con un soplo de insuficiencia vascular aórtica de novo(p=0,019, IC del 95 %: 1,3-20,1). La probabilidad de tener una enfermedad aguda grave alternativa fue 3,2 veces mayor en los pacientes con hipotensión o choque (p=0,02, IC del 95 %: 1,2-8,5). Conclusión: El uso de un SADC en el servicio de Urgencias puede ayudar a optimizar el diagnóstico del SAA. Se demostró que la presencia de un aneurisma aórtico conocido y de insuficiencia valvular aórtica de nueva aparición aumentan significativamente la probabilidad de SAA. Se necesitan más estudios para establecer una regla de predicción clínica.(AU)

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.(AU)

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.

Neumotórax masivo bilateral / Bilateral massive pneumothorax

No disponible

Manejo del status epiléptico / Management of epileptic status

No disponible

Cattle, pets, and Paget's disease of bone.

To identify animal-related factors associated with Paget's disease of bone (osteitis deformans), we conducted a case-control study in two geographical areas of Spain characterized by different socioeconomic profiles. The analysis presented here is based on 149 cases and 150 controls, frequency matched by sex, age, study area, and place of residence in youth (urban/rural). From a logistic regression analysis, we found that contact with bovine cattle [odds ratio (OR) = 2.14; 95% confidence interval (CI) = 1.16-3.94], consumption of meat traceable to sick livestock (OR = 2.70; 95% CI = 0.98-7.43), and frequent consumption during youth of brains (OR = 1.77; 95% CI = 1.05-2.98) and other viscera increased the risk for Paget's disease of bone. Contact with bovine cattle and consumption during youth of bovid viscera exhibited a dose-response effect as regards length of exposure and frequency of consumption, respectively. A life-style shared with dogs showed itself to be differentially linked to the disease in one study area. Overall, our results support the hypothesis that various animal species are carriers of etiologic agents of Paget's disease of bone.

Frequency and characteristics of familial aggregation of Paget's disease of bone.

The cause of Paget's disease of bone (PDB) is unknown. In an attempt to ascertain the proportion of familial cases and evaluate the influence of genetic factors on the occurrence of the disease, a study was undertaken based on 35 PDB patients from our Unit. Their families were investigated, with the participation of a total of 128 first-degree relatives. Fourteen (40%) of these 35 index cases had at least one other first-degree relative affected with PDB and were defined as "familial." The remaining 21 (60%) were considered "sporadic." The frequency of males in the familial cases (79%) was significantly higher than among the sporadics (29%; p < or = 0.01). Mean age at diagnosis (63.1 +/- 12.6 vs. 71.3 +/- 8.7; p < or = 0.02), proportion of polyostotic cases (85.7% vs. 52.4%, p < or = 0.05), and mean number of involved bones per patient (4.36 +/- 2.50 vs. 2.33 +/- 1.93, p < or = 0.01) differ significantly in the familial and sporadic groups. The disease appears to be transmitted via both paternal and maternal sides, and pedigree analysis suggested an autosomal dominant inheritance or multifactorial mechanism. Apart from green-and-blue eye color, which was clearly associated with familial grouping (OR 6.25, 95% CI 1.15-37.16, p < or = 0.01), crude analysis on several genetically based traits and environmental variables revealed no other significant differences between the groups. The adjusted odds ratio estimated for green-and-blue eye color was 2.92 (95% CI 0.38-22.74).(ABSTRACT TRUNCATED AT 250 WORDS)

[Anti-ribosomal antibodies in systemic lupus erythematosus]. / Anticuerpos antirribosomales en le lupus eritematoso sistémico.

OBJECTIVES: To compare indirect immunofluorescence (IIF) with immunoblotting (IB) in the detection of antiribosomal antibodies (anti-P Ab) in patients with systemic lupus erythematosus (SLE) and to investigate the possible association between anti-P Ab with serological and clinical findings in SLE, particularly with neurological manifestations. METHODS: Serum specimens from 44 SLE patients and 10 healthy subjects were investigated for anti-P Ab using IB and IIF in rat triple substrate and HEp-2 cells. In SLE patients measurements were made of antinuclear Ab, anti-DNA ds Ab, anti-Sm Ab, anti-U1RNP Ab, anti-Ro Ab, and anti-La Ab. Clinical manifestations of SLE were collected retrospectively when the serological investigation was made. RESULTS: Of the 44 serum specimens tested, 9 showed a ribosomal pattern with triple rat substrate; 8 of them were IB positive (sensitivity 88%; specificity 97%); 12 serum specimens showed a ribosomal pattern with HEp-2 cells by the IIF technique, 9 were positive by IB (sensitivity 100%; specificity 91%). All ten healthy subjects were negative both with IIF and with IB. The nine patients with anti-P Ab in IB (20.45%) had anti-Ro Ab (55% vs. 37%), Anti-Sm Ab (33% vs. 22%, and U1RNP Ab (33% vs. 20%) more frequently than the 35 negative cases. Central nervous system disease (33 vs. 14%), and particularly seizures (33% vs. 5%) and psychosis (22% vs. 8%) were more common in cases with anti-P Ab, but as with serological associations, none of them reached a statistical signification. CONCLUSIONS: IIF with both rat triple substrate and HEp-2 cells is useful for the presumptive diagnosis of anti-P Ab in patients diagnosed with SLE. No significant serological or clinical association was found in patients with anti-P Ab, although neurological disease was more common in these cases.

[The long-term results of ethanehydroxydiphosphonate treatment in Paget's disease of bone]. / Resultados a largo plazo del tratamiento con etanohidroxi bifosfonato en la enfermedad ósea de Paget.

Long-term results after ethanohydroxy diphosphonate treatment (EHDP) using a dose of 5/7.5 mg/kg/day over a 2 to 18 months period (x = 6.8) in a group of 45 cases of Paget disease, out of which 24 (53%) are male, are presented. An exam was programmed before and after treatment (12, 24 and 60 months). A clinical remission occurred in 75% of patients which lasted for at least 5 years in 51% of them. The average reduction of alkaline phosphatase levels was approximately 50% of baseline values (p less than 0.001) maintained with small variations up to the end of the study. There was no relapse in the last control performed in 49% of cases and 9 of them are from a 5 year follow up. On the contrary 11 patients (24%) did not show biochemical relapse however none of the characteristics analyzed permit the prediction of the type of response. The doses do not significantly influence the intensity either. We have observed scarce radiologic modifications although two patients showed a discrete improvement in the first revision and a worsening at different stages of their evolution was evidenced in two more cases. Altogether, these results confirm the long-term efficacy of treatment with EHDP at low doses at which it presents few adverse effects. The possibility of an structural deterioration advises to avoid its use in those cases with lytic lesions in load-bearing bones.