[A registry of out-of-hospital cardiac arrest in Chile]. / Registro prospectivo de pacientes que presentan paro cardiorrespiratorio extrahospitalario en Santiago, Chile.

BACKGROUND: The rate of survival to hospital discharge is less than 10% for out-of-hospital cardiac arrest (OHCA). AIM: To develop and implement a Chilean prospective, standardized cardiac arrest registry following the Utstein criteria. MATERIAL AND METHODS: We conducted a prospective registry for patients presenting at an urban, academic, high complexity emergency department (ED) after having an OHCA. The facility serves approximately 10% of the national population. Data were registered and analyzed following the Utstein criteria for reporting OHCA. RESULTS: For three years, 289 patients aged 59 ± 19 years (63% men) were included. Fifty seven percent of patients were taken to a health care facility for the first medical assessment by relatives or witnesses and 34% was assisted and transferred by prehospital personnel. In the subgroup of non-traumatic OHCA, 28% (n = 54) received bystander cardiopulmonary resuscitation (CPR). The registered cardiac rhythms were asystole (61%), pulseless electrical activity (PEA) (25%) and ventricular tachycardia (VT) or ventricular fibrillation (VF) (11%). The overall survival rate to discharge from the hospital was 10%, while survival with mRankin score 0-1 was 5%. The median hospitalization length of stay was 18 days among those who survived, compared with five days for the group of patients that died during the hospital stay. CONCLUSIONS: OHCA is an important cause of death in Chile. The development of a national registry that follows the International Liaison Committee on Resuscitation guidelines is the first step to assess the profile of OHCA in the region. It will provide crucial information to identify prognostic factors and variables that can help develop standards of care and set up the basis to optimize cardiac arrest management within our country and region.

Early versus deferred anti-SARS-CoV-2 convalescent plasma in patients admitted for COVID-19: A randomized phase II clinical trial.

BACKGROUND: Convalescent plasma (CP), despite limited evidence on its efficacy, is being widely used as a compassionate therapy for hospitalized patients with COVID-19. We aimed to evaluate the efficacy and safety of early CP therapy in COVID-19 progression. METHODS AND FINDINGS: The study was an open-label, single-center randomized clinical trial performed in an academic medical center in Santiago, Chile, from May 10, 2020, to July 18, 2020, with final follow-up until August 17, 2020. The trial included patients hospitalized within the first 7 days of COVID-19 symptom onset, presenting risk factors for illness progression and not on mechanical ventilation. The intervention consisted of immediate CP (early plasma group) versus no CP unless developing prespecified criteria of deterioration (deferred plasma group). Additional standard treatment was allowed in both arms. The primary outcome was a composite of mechanical ventilation, hospitalization for >14 days, or death. The key secondary outcomes included time to respiratory failure, days of mechanical ventilation, hospital length of stay, mortality at 30 days, and SARS-CoV-2 real-time PCR clearance rate. Of 58 randomized patients (mean age, 65.8 years; 50% male), 57 (98.3%) completed the trial. A total of 13 (43.3%) participants from the deferred group received plasma based on clinical aggravation. We failed to find benefit in the primary outcome (32.1% versus 33.3%, odds ratio [OR] 0.95, 95% CI 0.32-2.84, p > 0.999) in the early versus deferred CP group. The in-hospital mortality rate was 17.9% versus 6.7% (OR 3.04, 95% CI 0.54-17.17 p = 0.246), mechanical ventilation 17.9% versus 6.7% (OR 3.04, 95% CI 0.54-17.17, p = 0.246), and prolonged hospitalization 21.4% versus 30.0% (OR 0.64, 95% CI, 0.19-2.10, p = 0.554) in the early versus deferred CP group, respectively. The viral clearance rate on day 3 (26% versus 8%, p = 0.204) and day 7 (38% versus 19%, p = 0.374) did not differ between groups. Two patients experienced serious adverse events within 6 hours after plasma transfusion. The main limitation of this study is the lack of statistical power to detect a smaller but clinically relevant therapeutic effect of CP, as well as not having confirmed neutralizing antibodies in donor before plasma infusion. CONCLUSIONS: In the present study, we failed to find evidence of benefit in mortality, length of hospitalization, or mechanical ventilation requirement by immediate addition of CP therapy in the early stages of COVID-19 compared to its use only in case of patient deterioration. TRIAL REGISTRATION: NCT04375098.

Prioritization for liver transplantation using the MELD score in Chile: Inequities generated by MELD exceptions.: A collaboration between the Chilean Liver Transplant Programs, the Public Health Institute and the National Transplant Coordinator.

INTRODUCTION AND AIM: The MELD score has been established as an efficient and rigorous prioritization system for liver transplant (LT). Our study aimed to evaluate the effectiveness of the MELD score as a system for prioritization for LT, in terms of decreasing the dropout rate in the waiting list and maintaining an adequate survival post-LT in Chile. MATERIALS AND METHODS: We analyzed the Chilean Public Health Institute liver transplant registry of candidates listed from October 15th 2011 to December 31st 2014. We included adult candidates (>15 years old) listed for elective cadaveric LT with a MELD score of 15 or higher. Statistical analysis included survival curves (Kaplan-Meier), log-rank statistics and multivariate logistic regression. RESULTS: 420 candidates were analyzed. Mean age was 53.6±11.8 years, and 244 were men (58%). Causes of LT included: Liver cirrhosis without exceptions (HC) 177 (66.4%); hepatocellular carcinoma (HCC) 111 (26.4%); cirrhosis with non-HCC exceptions 102 (24.3%) and non-cirrhotic candidates 30 (7.2%). LT rate was 43.2%. The dropout rate was 37.6% at 1-year. Even though the LT rate was higher, the annual dropout rate was significantly higher in cirrhotic candidates (without exceptions) compared with cirrhotics with HCC, and non-HCC exceptions plus non-cirrhotic candidates (47.9%; 37.2% and 24.2%, respectively, with p=0.004). Post-LT survival was 84% per year, with no significant differences between the three groups (p=0.95). CONCLUSION: Prioritization for LT using the MELD score system has not decreased the dropout rate in Chile (persistent low donor's rate). Exceptions generate inequities in dropout rate, disadvantaging patients without exceptions.

[Risk of falls among patients admitted to a medical-surgical ward. Analysis of 376 medical records]. / Prevalencia de pacientes con alto riesgo de caídas en un servicio médico-quirúrgico de un hospital universitario.

BACKGROUND: Detecting patients at risk of falls during hospital stay is of utmost importance to implement preventive measures. AIM: To determine the frequency of patients with a high risk of falls admitted to a medical-surgical ward. To assess the preventive measures implemented. MATERIALS AND METHODS: Review of medical records of 376 patients aged 20 to 97 years (28% older than 70 years) admitted to a clinical hospital in a period of four months. RESULTS: Eleven percent of patients had a history of falls, 50% had a sensory deficit, 68% had unstable gait, 8% had a neurological risk condition, 8% had drowsiness or disorientation, 4% had psychomotor agitation or delirium, 86 % used high risk medications, 73% used 2 or more high risk drugs and 72% were using devices that decrease mobility. One hundred forty-one patients (38%) had a high risk of falling. The mean age of the latter was 77 years, 89% had a sensory deficit, 96% had unstable gait, 4% had psychomotor agitation or delirium and 98% used high risk drugs. Less than 1% had a medical prescription of a caregiver, physical restraints or antipsychotics, however, 21% of patients had a caregiver. CONCLUSIONS: The percentage of patients with a high risk of falling is important. The main risk factors were sensory deficit, unstable gait and the use of high risk medications. The low frequency of preventive measures prescriptions is striking.

[Deterioration of vital signs as predictors of major medical emergencies in hospitalized patients]. / Alteración de signos vitales dentro de las 72 h previas a la activación de código azul en pacientes adultos hospitalizados de un hospital universitario.

BACKGROUND: Medical emergencies (ME) in hospitalized patients (cardiac and respiratory arrest, suffocation, asphyxia, seizures, unconsciousness) are associated with high morbidity and mortality. Most of these patients have signs of physiological deterioration prior to the appearance of the emergency. Early detection of warning signs by rapid response teams (RRT) may provide an opportunity for the prevention of major adverse events. AIM: To identify clinical signs predicting death, need for mechanical ventilation, or transfer to a more complex unit during the 72 hours prior to the activation of the ME code. To evaluate the association of each trigger with specific major adverse events. PATIENTS AND METHODS: Medical records of 184 hospitalized adult patients in whom the ME code was activated between 2009 and 2014 were reviewed. RESULTS: Seventy five percent patients who experienced a ME had predictive signs of poor clinical outcome. Polypnea and airway involvement were associated to mechanical ventilation. Hypotension and hypoxemia were associated with mortality. CONCLUSIONS: In the absence of RRT, special attention should be given to patients with polypnea, airway involvement, hypotension and desaturation, since these are associated with poor clinical outcomes.

[The impact of a better coordination between emergency and intensive care units in the care of critically ill patients]. / Medicina de urgencia y unidades de cuidados intensivos: Una alianza necesaria en busca de la mejoría de la atención de pacientes críticos.

The need for critical care services is increasing in Chile. Critical care beds and specialists in this area are scarce. In this article we discuss some aspects that hamper the care of critically ill patients from their arrival to the emergency department to their transfer to the ICU. Special emphasis is given to system saturation and its multiple causes. The benefits of an integrative approach between emergency medicine and critical care specialists are highlighted and some solutions are proposed to strengthen this partnership.

Clinical Prediction Tool to Assess the Likelihood of a Positive SARS-Cov-2 (COVID-19) Polymerase Chain Reaction Test in Patients with Flu-like Symptoms.

INTRODUCTION: The clinical presentation of coronavirus disease 2019 (COVID-19) overlaps with many other common cold and influenza viruses. Identifying patients with a higher probability of infection becomes crucial in settings with limited access to testing. We developed a prediction instrument to assess the likelihood of a positive polymerase chain reaction (PCR) test, based solely on clinical variables that can be determined within the time frame of an emergency department (ED) patient encounter. METHODS: We derived and prospectively validated a model to predict SARS-CoV-2 PCR positivity in patients visiting the ED with symptoms consistent with the disease. RESULTS: Our model was based on 617 ED visits. In the derivation cohort, the median age was 36 years, 43% were men, and 9% had a positive result. The median time to testing from the onset of initial symptoms was four days (interquartile range [IQR]: 2-5 days, range 0-23 days), and 91% of all patients were discharged home. The final model based on a multivariable logistic regression included a history of close contact (adjusted odds ratio [AOR] 2.47, 95% confidence interval [CI], 1.29-4.7); fever (AOR 3.63, 95% CI, 1.931-6.85); anosmia or dysgeusia (AOR 9.7, 95% CI, 2.72-34.5); headache (AOR 1.95, 95% CI, 1.06-3.58), myalgia (AOR 2.6, 95% CI, 1.39-4.89); and dry cough (AOR 1.93, 95% CI, 1.02-3.64). The area under the curve (AUC) from the derivation cohort was 0.79 (95% CI, 0.73-0.85) and AUC 0.7 (95% CI, 0.61-0.75) in the validation cohort (N = 379). CONCLUSION: We developed and validated a clinical tool to predict SARS-CoV-2 PCR positivity in patients presenting to the ED to assist with patient disposition in environments where COVID-19 tests or timely results are not readily available.

Intubation timing as determinant of outcome in patients with acute respiratory distress syndrome by SARS-CoV-2 infection.

PURPOSE: To determine whether time-to-intubation was associated with higher ICU mortality in patients with COVID-19 on mechanical ventilation due to respiratory insufficiency. MATERIALS AND METHODS: We conducted an observational, prospective, single-center study of patients with confirmed SARS-CoV-2 infection hospitalized with moderate to severe ARDS, connected to mechanical ventilation in the ICU between March 17 and July 31, 2020. We examined their general and clinical characteristics. Time-to-intubation was the time from hospital admission to endotracheal intubation. RESULTS: We included 183 consecutive patients; 28% were female, and median age was 62 years old. Eighty-eight patients (48%) were intubated before 48 h (early) and ninety-five (52%) after 48 h (late). Patients intubated early had similar admission PaO2/FiO2 ratio (123 vs 99; p = 0.179) but were younger (59 vs 64; p = 0.013) and had higher body mass index (30 vs 28; p = 0.006) compared to patients intubated late. Mortality was higher in patients intubated late (18% versus 43%), with admission PaO2/FiO2 ratio < 100 mmHg (OR 5.2; p = 0.011), of older age (OR 1.1; p = 0.001), and with previous use of ACE inhibitors (OR 4.8; p = 0.026). CONCLUSIONS: In COVID-19 patients, late intubation, Pafi <100, older age, and previous ACE inhibitors use were associated with increased ICU mortality.

Osteopenia and osteoporosis among treatment-experienced people living with HIV.

INTRODUCTION: Life expectancy of people living with human immunodeficiency (PLHIV) has increased mainly due to the accessibility and effectiveness of antiretroviral therapy (ART). However, adverse effects from long-term use of antiretrovirals, and the physiological changes associated with aging, may compromise the quality of life of PLHIV, in addition to causing new demands on the healthcare system. OBJECTIVES: Estimate the frequency of osteoporosis and osteopenia in patients on prolonged ART and to verify their associated factors. METHODS: A cross-sectional study was conducted in Belo Horizonte, Minas Gerais, Brazil, from August 2017 to June 2018, in a sample of PLHIV (age ≥ 18 years) who started ART between 2001 and 2005. Data were collected through face-to-face interviews, physical evaluation, laboratory tests, and Dual-Energy X-Ray Absorptiometry Screening (DEXA). The outcome of interest was presence of bone alteration, defined as presence of osteopenia or osteoporosis in DEXA. The association between the explanatory variables and the event was assessed through odds ratio (OR) estimate, with 95% confidence interval (CI). Multiple logistic regression was performed to evaluate factors independently associated with bone alteration. RESULTS: Among 92 participants, 47.8% presented bone alteration (19.6% osteoporosis and 28.2% osteopenia). The variables that remained in the final logistic regression model were age ≥ 50 years (OR: 12.53; 95% CI: 4.37-35.90) and current alcohol use (OR: 2.63; 95% CI: 0.94-7.37). CONCLUSIONS: This study showed a high frequency of bone changes, especially in PLHIV older than 50 years. This information is useful to stimulate the screening and timely intervention of this comorbidity of PLHIV on prolonged use of ART in order to prevent or minimize complications and new demands on the healthcare system.

Psychosocial Adjustment and Sociometric Status in Primary Education: Gender Differences.

The acceptance or rejection of classmates is one of the most widely recognized determinants of wellbeing in childhood. This study analyses psychosocial adjustment and sociometric status in primary education pupils, and possible differences by gender. A cross-sectional survey was undertaken in Huelva (Spain). The surveyed schools were selected using a stratified random sampling technique with both public and private elementary schools. Sample was composed of 247 4th grade students. Data revealed gender differences in psychosocial adjustment, particularly in terms of prosocial behavior in girls and behavioral problems in boys. Popular and rejected statuses presented opposing adjustment profiles, particularly in hyperactive symptoms and behavioral problems. When the sample was separated by gender, the differences between the types of status in emotional symptomatology and prosocial behavior disappeared. In addition, the differences between statuses were greater in boys, and were defined mainly by hyperactivity, whilst for girls these differences were more apparent in behavioral problems.

Intoxicación por antidepresivos tricíclicos / Tricyclic antidepressant poisoning

Introducción: el paciente intoxicado sigue siendo un desafío para el personal de salud. La intoxicación por antidepresivos tricíclicos (ATC) es un diagnóstico frecuente y una patología que puede llegar a ser muy grave. A pesar de que ha cambiado el objetivo terapéutico de estos fármacos a lo largo de los años, la alta disponibilidad de estos hace que su uso para intento de autolisis siga presentándose. Su presentación clínica es variada y dado el riesgo de mortalidad asociada, es importante que esta patología sea rápidamente reconocida por los médicos que los reciben para iniciar un manejo oportuno y eficaz. Objetivo: presentar el enfrentamiento inicial y manejo terapéutico de la intoxicación por ATC desde la perspectiva de la medicina de urgencia. Método: se realizó una revisión bibliográfica de la literatura científica sobre el manejo de un paciente intoxicado por ATC. Se presenta la evidencia actual de las intervenciones terapéuticas más utilizadas. respecto al manejo inicial y enfrentamiento de la intoxicación por antidepresivos tricíclicos, en el contexto de la atención en un servicio de urgencia. Conclusión: la intoxicación por ATC puede presentarse con síntomas leves y signos precoces, así como con síntomas graves e incluso fatales, dados principalmente por complicaciones cardiovasculres y neurológicas. Su manejo se basa en el reconocimiento precoz, medidas de soporte y terapias específicas según la clínica que presente.

Managing poisoned patients continues to be a challenge for health personnel. Tricyclic antidepressant are a frequent diagnosis, and a pathology their can be very serious. Although the therapeutic indications for these drugs have changed over the years, their high availability means that their use for suicidal attempts continues to be present. Its clinical presentation is varied and given the mortality risk, it is crucial that this entity must be rapidly recognized by the physicians who care for them to initiate timely and effective treatment. Objective: Present the initial management and therapeutic strategies for tricyclic antidepressant intoxication, from emergency medicine perspective. Method: Bibliographic review of the scientific literature on this subject. Current evidence of the most widely used therapeutic interventions is described regarding the initial management and disposition of tricyclic antidepressant intoxication in the emergency department.

Does osteogenic potential of clonal human bone marrow mesenchymal stem/stromal cells correlate with their vascular supportive ability?

BACKGROUND: Human bone marrow-derived mesenchymal stem/stromal cells (hBM MSCs) have multiple functions, critical for skeletal formation and function. Their functional heterogeneity, however, represents a major challenge for their isolation and in developing potency and release assays to predict their functionality prior to transplantation. Additionally, potency, biomarker profiles and defining mechanisms of action in a particular clinical setting are increasing requirements of Regulatory Agencies for release of hBM MSCs as Advanced Therapy Medicinal Products for cellular therapies. Since the healing of bone fractures depends on the coupling of new blood vessel formation with osteogenesis, we hypothesised that a correlation between the osteogenic and vascular supportive potential of individual hBM MSC-derived CFU-F (colony forming unit-fibroblastoid) clones might exist. METHODS: We tested this by assessing the lineage (i.e. adipogenic (A), osteogenic (O) and/or chondrogenic (C)) potential of individual hBM MSC-derived CFU-F clones and determining if their osteogenic (O) potential correlated with their vascular supportive profile in vitro using lineage differentiation assays, endothelial-hBM MSC vascular co-culture assays and transcriptomic (RNAseq) analyses. RESULTS: Our results demonstrate that the majority of CFU-F (95%) possessed tri-lineage, bi-lineage or uni-lineage osteogenic capacity, with 64% of the CFU-F exhibiting tri-lineage AOC potential. We found a correlation between the osteogenic and vascular tubule supportive activity of CFU-F clones, with the strength of this association being donor dependent. RNAseq of individual clones defined gene fingerprints relevant to this correlation. CONCLUSIONS: This study identified a donor-dependent correlation between osteogenic and vascular supportive potential of hBM MSCs and important gene signatures that support these functions that are relevant to their bone regenerative properties.

Registro prospectivo de pacientes que presentan paro cardiorrespiratorio extrahospitalario en Santiago, Chile / A registry of out-of-hospital cardiac arrest in Chile

BACKGROUND: The rate of survival to hospital discharge is less than 10% for out-of-hospital cardiac arrest (OHCA). AIM: To develop and implement a Chilean prospective, standardized cardiac arrest registry following the Utstein criteria. MATERIAL AND METHODS: We conducted a prospective registry for patients presenting at an urban, academic, high complexity emergency department (ED) after having an OHCA. The facility serves approximately 10% of the national population. Data were registered and analyzed following the Utstein criteria for reporting OHCA. RESULTS: For three years, 289 patients aged 59 ± 19 years (63% men) were included. Fifty seven percent of patients were taken to a health care facility for the first medical assessment by relatives or witnesses and 34% was assisted and transferred by prehospital personnel. In the subgroup of non-traumatic OHCA, 28% (n = 54) received bystander cardiopulmonary resuscitation (CPR). The registered cardiac rhythms were asystole (61%), pulseless electrical activity (PEA) (25%) and ventricular tachycardia (VT) or ventricular fibrillation (VF) (11%). The overall survival rate to discharge from the hospital was 10%, while survival with mRankin score 0-1 was 5%. The median hospitalization length of stay was 18 days among those who survived, compared with five days for the group of patients that died during the hospital stay. CONCLUSIONS: OHCA is an important cause of death in Chile. The development of a national registry that follows the International Liaison Committee on Resuscitation guidelines is the first step to assess the profile of OHCA in the region. It will provide crucial information to identify prognostic factors and variables that can help develop standards of care and set up the basis to optimize cardiac arrest management within our country and region.

Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality.

INTRODUCTION: Acute circulatory dysfunction in patients with sepsis can evolve rapidly into a progressive stage associated with high mortality. Early recognition and adequate resuscitation could improve outcome. However, since the spectrum of clinical presentation is quite variable, signs of hypoperfusion are frequently unrecognized in patients just admitted to the emergency department (ED). Hyperlactatemia is considered a key parameter to disclose tissue hypoxia but it is not universally available and getting timely results can be challenging in low resource settings. In addition, non-hypoxic sources can be involved in hyperlactatemia, and a misinterpretation could lead to over-resuscitation in an unknown number of cases. Capillary refill time (CRT) is a marker of peripheral perfusion that worsens during circulatory failure. An abnormal CRT in septic shock patients after ICU-based resuscitation has been associated with poor outcome. The aim of this study was to determine the prevalence of abnormal CRT in patients with sepsis-related hyperlactatemia in the early phase after ED admission, and its relationship with outcome. METHODS: We performed a prospective observational study. Septic patients with hyperlactemia at ED admission subjected to an initial fluid resuscitation (FR) were included. CRT and other parameters were assessed before and after FR. CRT-normal or CRT-abnormal subgroups were defined according to the status of CRT following initial FR, and major outcomes were registered. RESULTS: Ninety-five hyperlactatemic septic patients were included. Thirty-one percent had abnormal CRT at ED arrival. After FR, 87 patients exhibited normal CRT, and 8 an abnormal one. Patients with abnormal CRT had an increased risk of adverse outcomes (88% vs. 20% p<0.001; RR 4.4 [2.7-7.4]), and hospital mortality (63% vs. 9% p<0.001; RR 6.7 [2.9-16]) as compared to those with normal CRT after FR. Specifically, CRT-normal patients required less frequently mechanical ventilation, renal replacement therapy, and ICU admission, and exhibited a lower hospital mortality. CONCLUSIONS: Hyperlactatemic sepsis patients with abnormal CRT after initial fluid resuscitation exhibit higher mortality and worse clinical outcomes than patients with normal CRT.

[Assessment of negative stereotypes about old age in young people and adults]. / Evaluación de los estereotipos negativos hacia la vejez en jóvenes y adultos.

INTRODUCTION: Negative stereotypes towards ageing and the old age may negatively influence relationships and working with older people. The CENVE (Negative Stereotypes Towards Ageing) questionnaire is a validated Spanish tool designed to evaluate these stereotypes, but there are no evidence about its factorial structure with young people and adults. This factorial structure of CENVE is analysed in non-elderly subjects, and its relationship with various sociodemographic and experience-related indicators is also examined. METHOD: A total of 350 young people and adults completed the CENVE. Information on demographics, specialised academic training in aging, and level of contact with elderly people were also provided. An analysis was performed on the factorial structure of the questionnaire and its relationship with socio-demographic and experiential indicators. RESULTS: The analyses performed did not confirm the original structure in 3 sub-scales, suggesting an alternative one-dimensional structure. It also suggested the existence of different ageist stereotypes associated with the socio-demographic profile of non-elderly subjects (particularly related to educational level). Less conclusive results were obtained regarding former experience and level of information on aging. CONCLUSIONS: CENVE is a useful tool for evaluating ageism, but in the present article a one-dimensional correction is suggested for the non-elderly population.

Medication Overdoses at a Public Emergency Department in Santiago, Chile.

INTRODUCTION: While a nationwide poison control registry exists in Chile, reporting to the center is sporadic and happens at the discretion of the treating physician or by patients' self-report. Moreover, individual hospitals do not monitor accidental or intentional poisoning in a systematic manner. The goal of this study was to identify all cases of intentional medication overdose (MO) that occurred over two years at a large public hospital in Santiago, Chile, and examine its epidemiologic profile. METHODS: This study is a retrospective, explicit chart review conducted at Hospital Sótero del Rio from July 2008 until June 2010. We included all cases of identified intentional MO. Alcohol and recreational drugs were included only when they were ingested with other medications. RESULTS: We identified 1,557 cases of intentional MO and analyzed a total of 1,197 cases, corresponding to 0.51% of all emergency department (ED) presentations between July 2008 and June 2010. The median patient age was 25 years. The majority was female (67.6%). Two peaks were identified, corresponding to the spring of each year sampled. The rate of hospital admission was 22.2%. Benzodiazepines, selective serotonin reuptake inhibitors, and tricyclic antidepressants (TCA) were the causative agents most commonly found, comprising 1,044 (87.2%) of all analyzed cases. Acetaminophen was involved in 81 (6.8%) cases. More than one active substance was involved in 35% of cases. In 7.3% there was ethanol co-ingestion and in 1.0% co-ingestion of some other recreational drug (primarily cocaine). Of 1,557 cases, six (0.39%) patients died. TCA were involved in two of these deaths. CONCLUSION: Similar to other developed and developing nations, intentional MO accounts for a significant number of ED presentations in Chile. Chile is unique in the region, however, in that its spectrum of intentional overdoses includes an excess burden of tricyclic antidepressant and benzodiazepine overdoses, a relatively low rate of alcohol and recreational drug co-ingestion, and a relatively low rate of acetaminophen ingestion.

Usability and Workflow Evaluation of "RhEumAtic Disease activitY" (READY). A Mobile Application for Rheumatology Patients and Providers.

BACKGROUND: RhEumAtic Disease activitY (READY) is a mobile health (mHealth) application that aims to create a shared platform integrating data from both patients and physicians, with a particular emphasis on arthritis disease activity. METHODS: We made READY available on an iPad and pilot implemented it at a rheumatology outpatient clinic. We conducted 1) a usability evaluation study to explore patients' and physicians' interactions with READY, and 2) a time motion study (TMS) to observe the clinical workflow before and after the implementation. RESULTS: A total of 33 patients and 15 physicians participated in the usability evaluation. We found usability problems in navigation, data entry, pain assessment, documentation, and instructions along with error messages. Despite these issues, 25 (75,76%) patients reported they liked READY. Physicians provided mixed feedback because they were concerned about the impact of READY on clinical workflow. Six physicians participated in the TMS. We observed 47 patient visits (44.72 hours) in the pre-implementation phase, and 42 patient visits (37.82 hours) in the post-implementation phase. We found that patients spent more time on READY than paper (4.39mins vs. 2.26mins), but overall, READY did not delay the workflow (pre = 52.08 mins vs. post = 45.46 mins). This time difference may be compensated with READY eliminating a workflow step for the staff. CONCLUSION: Patients preferred READY to paper documents. Many found it easier to input information because of the larger font size and the ease of 'tapping' rather than writing-out or circling answers. Even though patients spent more time on READY than using paper documents, the longer usage of READY was mainly due to when troubleshooting was needed. Most patients did not have problems after receiving initial support from the staff. This study not only enabled improvements to the software but also serves as good reference for other researchers or institutional decision makers who are interested in implementing such a technology.

Disnea en el servicio de urgencia / Dyspnea in the emergency deparmen

La disnea es definida como la sensación subjetiva de ahogo o falta de aire y es un motivo muy frecuente de consulta. Su presentación clínica puede variar, desde manifestaciones leves hasta insuficiencia respiratoria catastrófica, con elevada mortalidad y requerir de terapias invasivas complejas. En los servicios de urgencia se inicia el estudio etiológico del paciente agudo, al mismo tiempo que se realizan intervenciones terapéuticas destinadas a la estabilización y manejo tiempo-dependiente del paciente que consulta por disnea. En vista de las múltiples causas de disnea, es necesario que el especialista en medicina de urgencia conozca los distintos diagnósticos diferenciales y sepa orientar su manejo y estudio. Este manuscrito pretende dar un marco teórico acerca de la presentación del paciente con disnea en el servicio de urgencia, describir sus principales características y orientar el estudio y tratamientos tiempo-dependientes desde su primera evaluación por el equipo médico. Se expone un caso clínico y revisan los componentes esenciales de la fisiopatología que explica la disnea, así como la descripción de herramientas para su evaluación, tratamiento y disposición en el servicio de urgencia. Finalizaremos con la resolución del caso.

Dyspnea, defined as the subjective feeling of shortness of breath, it's a common complaint in emergency departments all over the world. The clinical presentation may include mild symptoms to severe respiratory distress with the requirement of mechanical ventilation. This implies high mortality rates and complex decision-making involving diagnostics, treatment, and invasive management in all groups of ages.It is paramount for the emergency medicine physician to acknowledge its vastly differential diagnostics and be familiarized with time-dependent actions to properly stabilization and treatment. This article aims to review the presentation of dyspneic patients in the Emergency Department, describes the main physiologic characteristics, guide diagnosis, and treatment since the very first-minute patient steps into the hospital. It will present clinical scenarios and handle valuable tools for evaluation and treatment strategies in dyspneic patients while they stay in the Emergency Department.

A Novel Multiple Choice Question Generation Strategy: Alternative Uses for Controlled Vocabulary Thesauri in Biomedical-Sciences Education.

Multiple choice questions play an important role in training and evaluating biomedical science students. However, the resource intensive nature of question generation limits their open availability, reducing their contribution to evaluation purposes mainly. Although applied-knowledge questions require a complex formulation process, the creation of concrete-knowledge questions (i.e., definitions, associations) could be assisted by the use of informatics methods. We envisioned a novel and simple algorithm that exploits validated knowledge repositories and generates concrete-knowledge questions by leveraging concepts' relationships. In this manuscript we present the development and validation of a prototype which successfully produced meaningful concrete-knowledge questions, opening new applications for existing knowledge repositories, potentially benefiting students of all biomedical sciences disciplines.