Rendimiento diagnóstico de la troponina de alta sensibilidad en el síndrome coronario agudo sin elevación del segmento ST / Diagnostic performance of high sensitive troponin in non-ST elevation acute coronary syndrome

Objetivo: Los objetivos del estudio son evaluar el rendimiento diagnóstico de la troponina cardiaca T de alta sensibilidad (TnTc-hs) en pacientes con sospecha de síndrome coronario agudo sin elevación del segmento ST (SCASEST), confirmar si permite acortar el tiempo hasta el diagnóstico y analizar las consecuencias clínicas derivadas de su utilización. Método: Se trata de un estudio observacional, longitudinal y prospectivo, realizado en 5 servicios de urgencias hospitalarias. Se incluyó de forma consecutiva a los pacientes que acudían por dolor torácico sospechoso de SCASEST. El manejo del paciente y el tratamiento aplicado siguieron los protocolos internos basados en las guías de consenso de la Sociedad Europea de Cardiología. Se realizaron determinaciones seriadas de Tnc convencional (4ªG) y de TnTc-hs. Resultados: Se incluyó en el estudio a 351 pacientes. El diagnóstico final de infarto agudo de miocardio (IAM) se estableció en 77 pacientes del total, angina inestable en 102 y 172 fueron pacientes diagnosticados como sin síndrome coronario agudo. Los valores de TnTc-hs estaban por encima del p99 en un alto número de pacientes sin IAM. En la determinación inicial del paciente, la sensibilidad diagnóstica de la TnTc-hs fue significativamente superior a la de la TnTc 4ªG (87,0 vs. 42,9%), lo que comportó un valor predictivo negativo del 95,1%. Conclusiones: La TnTc-hs mejora el rendimiento diagnóstico al compararla con el ensayo de Tnc convencional, acorta el tiempo hasta el diagnóstico y reconoce mayor número de pacientes con IAM más pequeños

Objective: To assess the diagnostic performance of high-sensitivity troponin T (hs-TnT) in patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS); confirm whether it shortens the time to diagnosis; and analyze the clinical consequences derived from its use. Method: A prospective, longitudinal observational study was carried out in 5 emergency care departments. Patients seen for chest pain with suspected of NSTE-ACS were consecutively included. Patient care followed the internal protocols of the center, based on the consensus guidelines of the European Society of Cardiology. Serial conventional cardiac troponin (cTn) and hs-TnT determinations were made. Results: A total of 351 patients were included in the study. A final diagnosis of acute myocardial infarction (AMI) was established in 77 patients, with unstable angina in 102, and no acute coronary syndrome in 172 patients. The hs-TnT values were above percentile 99% in a large number of patients without AMI. In the initial determination, the diagnostic sensitivity of the hs-TnT was significantly greater than that of cTn (87.0% vs. 42.9%), which led to a negative predictive value of 95.1%. Conclusions: High-sensitivity troponin T improves diagnostic performance compared with conventional troponin assay, shortens the time to diagnosis, and identifies a larger number of patients with smaller myocardial infarctions

Diagnostic performance of high sensitive troponin in non-ST elevation acute coronary syndrome. / Rendimiento diagnóstico de la troponina de alta sensibilidad en el síndrome coronario agudo sin elevación del segmento ST.

OBJECTIVE: To assess the diagnostic performance of high-sensitivity troponin T (hs-TnT) in patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS); confirm whether it shortens the time to diagnosis; and analyze the clinical consequences derived from its use. METHOD: A prospective, longitudinal observational study was carried out in 5 emergency care departments. Patients seen for chest pain with suspected of NSTE-ACS were consecutively included. Patient care followed the internal protocols of the center, based on the consensus guidelines of the European Society of Cardiology. Serial conventional cardiac troponin (cTn) and hs-TnT determinations were made. RESULTS: A total of 351 patients were included in the study. A final diagnosis of acute myocardial infarction (AMI) was established in 77 patients, with unstable angina in 102, and no acute coronary syndrome in 172 patients. The hs-TnT values were above percentile 99% in a large number of patients without AMI. In the initial determination, the diagnostic sensitivity of the hs-TnT was significantly greater than that of cTn (87.0% vs. 42.9%), which led to a negative predictive value of 95.1%. CONCLUSIONS: High-sensitivity troponin T improves diagnostic performance compared with conventional troponin assay, shortens the time to diagnosis, and identifies a larger number of patients with smaller myocardial infarctions.

Bacteriemia en pacientes adultos dados de alta en el servicio de urgencias / Bacteraemia in adult patients discharged from Emergency department

INTRODUCCIÓN: La bacteriemia constituye un marcador de gravedad de los procesos infecciosos. Sin embargo, en ocasiones se extraen hemocultivos en urgencias a pacientes que son dados de alta estando pendiente su resultado. MATERIAL Y MÉTODOS: Estudio prospectivo de las bacteriemias de la población adulta del servicio de urgencias de un hospital universitario de tercer nivel de marzo de 2014 a febrero de 2015. Se analizaron las características epidemiológicas, clínicas y microbiológicas de los pacientes con bacteriemia que ingresaron y de los que fueron dados de alta. Tras la detección de la bacteriemia, el servicio de microbiología avisó telefónicamente al médico responsable del paciente (paciente ingresado) o al médico de atención primaria (paciente dado de alta). RESULTADOS: Se incluyeron 429 episodios de bacteriemia. Fueron dados de alta el 13,52%. Estos pacientes eran más jóvenes (68,5 vs 73,59 años; p = 0,0001), tenían menor índice de Charlson (1,603 vs 2,309; p = 0,0013) y menor gravedad (shock séptico 0 vs 34, p < 0,0001) que los pacientes que fueron ingresados. Tras la llamada a atención primaria se inició antibiótico oral en el 10,3%, se cambió el antibiótico oral en el 6,9%, fueron ingresados el 12% y el resto continuaron el tratamiento pautado. No se registró mortalidad a los 30días. CONCLUSIONES: Los pacientes dados de alta representan un número considerable. Remitir a un paciente con hemocultivos cursados desde urgencias a domicilio, en situación de estabilidad clínica, es una práctica segura, siempre que exista una reevaluación del paciente en caso de positividad de los mismos

INTRODUCTION: Bacteraemia is a marker of severity of infectious processes. However, sometimes in Emergency Department blood cultures are drawn from patients who are discharged without results being available. MATERIAL AND METHODS: Prospective study of bacteraemia was conducted on adult patients from Emergency Department of tertiary university hospital from March 2014 to February 2015. Epidemiological, clinical and microbiological data were collected from patients admitted and discharged. After the detection of bacteraemia, the microbiology department telephoned the physician responsible (patients admitted) or Primary Care physician (patients discharged). RESULTS: A total of 429 episodes of bacteraemia were included, of which 13.52% were discharged. These patients were younger (68.5 vs 73.59 years, P=.0001), had a lower Charlson index (1.603 vs 2.309, P=.0013) and lower severity (septic shock 0 vs 34; P<.0001) than admitted patients. After the call to Primary Care, oral antibiotics were started in 10.3%, a change in oral antibiotic in 6.9%, 12% were admitted to hospital, and the rest of them continued same treatment. The 30-day mortality rate was 0%. CONCLUSIONS: There was a significant number of patients with bacteraemia were discharged from Emergency Department. To discharge a clinically stable patient with blood cultures taken in Emergency Department is safe, if there is a re-assessment of the patient if these cultures are positive

[Bacteraemia in adult patients discharged from Emergency department]. / Bacteriemia en pacientes adultos dados de alta en el servicio de urgencias.

INTRODUCTION: Bacteraemia is a marker of severity of infectious processes. However, sometimes in Emergency Department blood cultures are drawn from patients who are discharged without results being available. MATERIAL AND METHODS: Prospective study of bacteraemia was conducted on adult patients from Emergency Department of tertiary university hospital from March 2014 to February 2015. Epidemiological, clinical and microbiological data were collected from patients admitted and discharged. After the detection of bacteraemia, the microbiology department telephoned the physician responsible (patients admitted) or Primary Care physician (patients discharged). RESULTS: A total of 429 episodes of bacteraemia were included, of which 13.52% were discharged. These patients were younger (68.5 vs 73.59 years, P=.0001), had a lower Charlson index (1.603 vs 2.309, P=.0013) and lower severity (septic shock 0 vs 34; P<.0001) than admitted patients. After the call to Primary Care, oral antibiotics were started in 10.3%, a change in oral antibiotic in 6.9%, 12% were admitted to hospital, and the rest of them continued same treatment. The 30-day mortality rate was 0%. CONCLUSIONS: There was a significant number of patients with bacteraemia were discharged from Emergency Department. To discharge a clinically stable patient with blood cultures taken in Emergency Department is safe, if there is a re-assessment of the patient if these cultures are positive.

Diagnóstico no invasivo de amiloidosis cardiaca por transtirretina. Caso clínico / Non-invasive diagnosis of cardiac amyloidosis due to transthyretin. Case report

La amiloidosis cardiaca por transtirretina se considera en la actualidad la forma más frecuente de amiloidosis cardiaca y su incidencia está aumentando gracias al avance de las técnicas de diagnóstico por imagen. Recientemente se han publicado unos criterios de diagnóstico no invasivo para esta entidad, y se están desarrollando nuevos fármacos para el tratamiento específico de este tipo de amiloidosis cardiaca. Por ello, la amiloidosis cardiaca por transtirretina podría pasar de ser una enfermedad rara a frecuente, y de incurable a potencialmente tratable. Presentamos el caso de un varón de 80 años diagnosticado de amiloidosis cardiaca mediante gammagrafía con 99mTc dicarboxipropano difosfonato (99mTc-DPD) según los nuevos criterios de diagnóstico no invasivo

Amyloidosis due to deposits of transthyretin (ATTR) is currently considered the most frequent form of cardiac amyloidosis and its incidence is increasing thanks to the advances in diagnostic imaging techniques. Some non-invasive diagnostic criteria have recently been published on this entity that due to the development of new drugs for the specific treatment of cardiac ATTR, have prognostic and therapeutic implications. That is why cardiac ATTR could cease to be a rare disease and become a frequent one, and become potentially treatable instead of incurable. We present the case of an 80-year-old male diagnosed with non-hereditary cardiac ATTR by means of gammagraphy with 99mTc diphosfonate scintigraphy (99mTc-DPD) following the new criteria of non-invasive diagnosis

[Non-invasive diagnosis of cardiac amyloidosis due to transthyretin. Case report]. / Diagnóstico no invasivo de amiloidosis cardiaca por transtirretina. Caso clínico.

Amyloidosis due to deposits of transthyretin (ATTR) is currently considered the most frequent form of cardiac amyloidosis and its incidence is increasing thanks to the advances in diagnostic imaging techniques. Some non-invasive diagnostic criteria have recently been published on this entity that due to the development of new drugs for the specific treatment of cardiac ATTR, have prognostic and therapeutic implications. That is why cardiac ATTR could cease to be a rare disease and become a frequent one, and become potentially treatable instead of incurable. We present the case of an 80-year-old male diagnosed with non-hereditary cardiac ATTR by means of gammagraphy with 99mTc diphosfonate scintigraphy (99mTc-DPD) following the new criteria of non-invasive diagnosis.

Intervención educativa para implantar un protocolo de tratamiento de la hiperglucemia en urgencias / Educational intervention to introduce an emergency department hyperglycemia treatment protocol

Objetivos: Evaluar el efecto una intervención educativa en el servicio de urgencias (SU)dirigida a implementar un protocolo de tratamiento de la hiperglucemia. La hipótesis de partida fue que la intervención educativa dirigida a los profesionales del SU permitiría aumentar el uso de la pauta basal-bolo en el tratamiento de la hiperglucemia hospitalaria. Método: Estudio cuasi-experimental con un grupo de control no equivalente, pre/post intervención formativa. Se seleccionaron dos grupos de pacientes (pre y post intervención) mediante muestreo consecutivo, mayores de 18 años y hospitalizados desde el SU con diagnóstico de diabetes tipo 2 e hiperglucemia mayor de 180 mg/dl. Las variables de resultado analizadas fueron la proporción de pacientes tratados con pauta basal-bolo y el grado de control de la glucemia [días transcurridos hasta el control de la (..) (AU)

Objectives: To assess an emergency department (ED) educational intervention leading to implementation of a hyperglycemia treatment protocol. Our hypothesis was that the ED educational intervention would increase use of basal bolus therapy for hospital management of hyperglycemia. Methods: Quasi-experimental pre-post intervention study comparing unmatched groups. Patients treated before and after the intervention were selected consecutively. All were over the age of 18 years and admitted from the ED with a diagnosis oftype-2 diabetes and a blood sugar level over 180 mg/dL. The variables analyzed were percentage of patients in each group treated with basal-bolus therapy, and the degree of glycemic control (days until blood sugar levels were brought under control, mean blood sugar levels, and number of hyperglycemic [>180 mg/dL], and hypoglycemic [<60 mg/dL] episodes).Results: A total of 96 patients (preintervention, 45; postintervention, 51) were included. The use of basal-bolus therapy (..) (AU)

Nuevos fármacos antiagregantes en el síndrome coronario agudo y su utilización en el servicio de urgencias / New platelet aggregation inhibitors in acute coronary syndrome in the emergency department

En los últimos años ha habido novedades significativas en las estrategias de manejo yen los fármacos utilizados en el tratamiento del síndrome coronario agudo (SCA). Hasta hoy, las guías de práctica clínica recomendaban el uso de doble terapia antiagregante con aspirina y clopidogrel. Dos nuevos inhibidores del receptor P2Y12 (prasugrel y ticagrelor) han sido aprobados como tratamiento del SCA, y muestran una inhibición plaquetaria más rápida y más eficaz. Esta incorporación a la práctica clínica implica un cambio importante en el manejo de estos pacientes en su fase aguda. Se revisa brevemente la fisiopatología del proceso trombótico, los inicios de la antiagregación y los ensayos clínicos llevados a cabo con estos nuevos fármacos, así como su utilización en los servicios de urgencias (AU)

New pharmacologic strategies for managing acute coronary syndrome (ACS) have emerged in recent years. Clinical guidelines continue to recommend dual antiplatelet therapy with aspirin and clopidogrel. Two recently approved P2Y12inhibitors, prasugrel and ticagrelor, have been shown to act faster and more effectively in treating ACS. These drugs mark an important turning point in the emergency management of ACS. We briefly review the pathophysiology of the thrombotic process and recall the early history of antiplatelet therapy. We explain the results of clinical trials of these new drugs and their use in the emergency department (AU)

Instrucción en maniobras de soporte vital básico mediante video juegos a escolares: comparación de resultados frente a un grupo control / Video-game instruction in basic life support maneuvers

Objetivos: Determinar la capacidad de un videojuego educativo para enseñar conocimientos teóricos sobre soporte vital básico a alumnos de instituto, y compararlo con el método tradicional de enseñanza, basado en la demostración práctica de los procedimientos por personal sanitario. Método: Desarrollo de un videojuego educativo basado en las recomendaciones ILCOR2010. Se incluyó a 344 alumnos de institutos de Aragón (España), repartidos entre los grupos control y experimental. La valoración de conocimiento se realizó mediante dos cuestionarios, uno antes y otro después de la experiencia, con la finalidad de detectar cambios. Resultados: Se utilizaron datos de 331 alumnos. Los 187 alumnos del grupo experimental pasaron de una nota media de 5,41 antes de utilizar el juego a una nota media de 7,48, y los 144 del grupo de control de 4,95 a 8,56. Las diferencias, entre las dos notas en cada grupo, se consideraron significativas, y estos cambios también fueron estadísticamente diferentes entre los dos grupos, con mayor incremento en el grupo control. Conclusiones: El grupo experimental consiguió un incremento significativo en sus conocimientos teóricos, aunque éste es menor que el conseguido por el grupo de control. Los resultados son relevantes, ya que el nuevo método tiene un coste por sesión significativamente menor (el juego puede ser utilizado sin supervisión y de forma ilimitada) y se encuentra disponible de manera gratuita y libre para su reutilización por instituciones o individuos (AU)

Objectives: 1) To assess the usefulness of an educational video game to teach the theory of basic life support to high school students; 2) to compare video-game instruction to the traditional teaching of basic life support maneuvers through practical demonstrations by health care professionals. Methods: An educational video game was developed according to the ILCOR 2010 guidelines. The study was carried out in a sample of 344 secondary school students in Aragon, Spain. The students, who were allocated to an experimental group and a control group, took a test before and after instruction in order to detect change in knowledge. Results: Viable data were obtained for 331 students. The 187 students in the experimental group had a mean grade of5.41 (out of a maximum score of 10) before playing the game and a mean grade of 7.48 afterwards. Students in the control group had a mean grade of 4.95 before and 8.56 afterwards. The differences in each group were significant (..) (AU)

Factores pronóstico a corto plazo en los ancianos atendidos en urgencias por síndrome coronario agudo con elevación del segmento ST / Short-term prognostic factors in elderly patients treated in emergency departments

Objetivo: Investigar los factores asociados a la mortalidad a corto plazo en los pacientes ancianos que acuden a urgencias por síndrome coronario agudo con elevación del segmento ST (SCAEST).Método: Estudio multicéntrico, longitudinal, observacional, analítico-prospectivo y sin intervención. Se incluyó a pacientes de 70 o más años atendidos en 42 hospitales españoles. Se analizaron 17 variables independientes que pudieran influir en la mortalidad a 30 días. Los datos se obtuvieron a partir de un registro creado para este estudio, de la historia clínica o de la entrevista con el paciente o sus familiares. Se realizó un estudio multivariable mediante regresión logística. Resultados: Se incluyó a 1.137 pacientes, 340 (29,9%) fallecieron a los 30 días de la consulta en urgencias. Cuatro variables se asociaron de forma significativa con la mortalidad: la edad (odds ratio [OR] = 2,71; intervalo de confianza [IC] del 95%, 2,02-3,64), la no realización de angioplastia primaria (AP) (OR = 3; IC del 95%, 1,32-6,81)la clasificación de Killip avanzada (OR = 10,19; IC del 95%, 6,99 -14,85) y la localización anterior del infarto (OR = 1,39; IC del 95%, 1,03-1,86).Conclusiones: Encontramos diversos factores disponibles tras la valoración en urgencias, como la edad, que determinan un mal pronóstico a corto plazo del paciente anciano que consulta por un SCAEST. Ni la clase de Killip, ni la localización anterior del infarto agudo de miocardio ni la edad son susceptibles de modificación, no así la realización de una AP que, a diferencia del tratamiento fibrinolítico, es un factor independiente de no mortalidad a los 30 días (AU)

Objective: To identify factors associated with short-term mortality in patients of advanced age who come to the emergency department with acute coronary syndrome with ST segment elevation.Methods: Prospective longitudinal observational multicenter analytic study without interventions. Patients aged 70 yearsor older who were treated at 42 Spanish hospitals were included. Seventeen independent variables that might influence30-day mortality were analyzed. The information was extracted from the medical records or obtained during interviews with the patient or a family member; it was then recorded in a database developed for this study.Results: A total of 1137 patients were included; 340 (29.9%) died within 30 days of the emergency department visit.Four variables conferred significant risk of mortality. These were age (odds ratio [OR], 2.71; 95% confidence interval [CI],2.02-3.64); lack of primary angioplasty (OR, 3; 95% CI, 1.32-6.81); advanced Killip class (OR, 10.19; 95% CI, 6.99-14.85); and anterior location of the lesion (OR, 1.39; 95% CI, 1.03-1.86).Conclusions: We identified several factors, such as age, that are recorded during emergency department assessment andthat predict poor short-term outcome in the elderly patient treated for acute coronary syndrome with ST segment elevation. Although Killip class, location of the acute myocardial infarction, and age cannot be modified, we did identify a factor (performance of primary angioplasty) that, unlike fibrinolytic treatment, is independently associated with a better outcome in terms of 30-day mortality (AU)

La asistencia urgente del infarto de miocardio con elevación del segmento ST en España: objetivos y diseño del Registro en Emergencias del Infarto de Miocardio (RESIM) / Emergency care of acute myocardial infarction with ST-segment elevation in Spain: Aims and design of registry of acute myocardial infarction in the emergency departments (RESIM)

Objetivos: RESIM es un registro diseñado para estudiar las características de la atención al infarto agudo de miocardio en los servicios de urgencias hospitalarios españoles. Los objetivos de este estudio son conocer las características epidemiológicas de los pacientes, analizar las demoras hasta la llegada al hospital y el inicio del tratamiento y describir las estrategias de manejo y la utilización del tratamiento fibrinolítico en los servicios de urgencias hospitalarios. Métodos: Estudio prospectivo, multicéntrico y observacional realizado en el ámbito de los servicios de urgencias hospitalarios españoles. Se incluyen de forma consecutiva los pacientes asistidos por síndrome coronario con elevación del segmento ST o bloqueo de rama agudo. Se recogen las variables epidemiológicas, clínicas, horarios de asistencia y actuaciones realizadas tanto en el nivel prehospitalario como hospitalario. Se analiza la mortalidad en el servicio de urgencias, la mortalidad hospitalaria y la mortalidad a 30 días. Conclusiones: RESIM es el primer registro español de la asistencia del infarto de miocardio con ST elevado en urgencias, por lo que aportará información hasta ahora desconocida sobre el papel de los servicios de urgencias hospitalarios en el manejo de estos pacientes. RESIM constituye una herramienta útil para la mejora continua de la calidad del proceso asistencial de estos pacientes (AU)

Hemorragia mediastínica tras implantación de catéter venoso central / Mediastinal haemorrhage after the insertion of a central venous catheter

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Recomendaciones en profilaxis postexposición ocupacionaly no ocupacional frente al VIH / Recommendations for prophylaxis after occupational and non-occupational exposure to HIV

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Bibliografía Internacional

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[Cerebellar syndrome as first manifestation of late onset systemic lupus erythematosus]. / Síndrome cerebeloso como primera manifestación de un lupus eritematoso sistémico de inicio tardío.

Clinical characteristics of a 70-year-old women affected by an erythematous systemic lupus (ESL) of late onset, whose first main manifestation was the compromise of the central nervous system as cerebellar syndrome and which exhibited a good response to treatment, is described. Pathogenic and diagnostic aspects of the neurological manifestations of ESL are described.

[Acute HIV infection]. / Infección aguda por VIH.

OBJECTIVE: Primary HIV infection presents a non-specific and polymorphous clinical profile. We present two cases which show how a high level of clinical awareness can lead to an early diagnosis. DESIGN: A retrospective study of all the HIV positive patients treated in Zaragoza's Miguel Servet Hospital between 1985 and 1991 was carried out. Site. The medical records studied concerned the hospital as regards admissions and out-patient consultations. PATIENTS: The two cases which we contributed fulfilled the serologic criteria of acute HIV infection. MAIN MEASUREMENTS AND RESULTS: The man-woman relationship was 1/1. The only way of contagion found was heterosexual. Predominant clinical symptoms were cutaneous-mucous, with a prominent condition of oesophagitis produced by Candida. CONCLUSIONS: A high level of clinical awareness on the part of the Primary Care doctor can contribute significantly to the detection of new cases and controlling the HIV epidemic.

[Tuberculosis caused by Mycobacterium bovis: apropos of 2 cases]. / Tuberculosis causada por Mycobacterium bovis: a propósito de dos casos.

Infection by Mycobacterium bovis is currently a rare form of tuberculosis in developed countries, being its incidence lower than 1%. Its main mechanism of transmission is through the ingestion of contaminated milk. In this paper, two cases of tuberculosis by Mycobacterium bovis are described, one of lymphatic location by endogenous reactivation and another of pulmonary location, probably by a primary infection acquired through the inhalation route. We stress the risk of transmission of the disease through the respiratory route from infected animals and by person to person contagion.

[Pulmonary fibrosis as a presentation form of the Jo-1 syndrome]. / Fibrosis pulmonar como forma de presentación del síndrome Jo-1.

Jo-1 syndrome is a disease recently described, included on the list of connective tissue diseases. Its clinical features are myositis and/or pulmonary fibrosis associated to the presence of precipitant antibodies against intracellular enzyme call histidine T-RNA synthetase. This antibody is related to pulmonary fibrosis associated to myositis and some scientist gave predictive value on the onset of pulmonary fibrosis in patients with myositis. However, isolated association of pulmonary fibrosis have been exceptionally described. A patient with severe interstitial pulmonary affliction and positive Jo-1 antibody without myositis is presented. The actual knowledge of the disease and its association is reviewed.