Psychological symptoms in difficult-to-sedate critical care survivors.

BACKGROUND: Critical care survivors often experience symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD). AIMS: To determine the prevalence and severity of psychological symptoms during the first 6 months after discharge from the intensive care unit (ICU) and to evaluate its association with patients who are difficult to sedate during admission. DESIGN: Descriptive, prospective analysis of psychological symptoms in survivors from medicosurgical ICU over a 2-year period. METHODS: All ICU survivors who required mechanical ventilation (MV) for more than 24 hours were followed for 6 months after their ICU discharge. ICU outcome and complications as well as the presence of psychological symptoms, 1 to 3 to 6 months after discharge were prospectively evaluated through phone interviews comparing the incidence and intensity of patients who were difficult to sedate during their ICU stay with those who were not. Descriptive analysis and multivariate logistic regression were performed. RESULTS: Data were obtained for 195 patients, of whom 30% experienced difficult sedation (DS). Difficult-to-sedate patients were younger (P = .001), less critically ill (APACHE II score P = .002), and more likely to engage in harmful use of alcohol (P = .001) and psychoactive/psychotropic drug abuse. They also spent longer times on MV and in the ICU (P = .001). Anxiety incidence at 1 to 3 to 6 months post-discharge was significantly higher in DS patients than in those who were not (87.7% vs 45.4%, 75.5% vs 29.0%, and 70.8% vs 23.7%; P < .01), respectively. Depression incidence was also significantly higher in the DS group (82.4% vs 43.1%, 66% vs 33.9%, and 60.4% vs 27.2%; [P = .001]) at 1 to 3 to 6 months, respectively. A higher percentage of patients in the DS group reported symptoms of PTSD at 1 month (28.1% vs 11.5%) (P = .007) when compared with non-DS group. CONCLUSIONS: Critical care survivors who are difficult to sedate during their ICU stay are more likely to present psychological sequelae. Early identification of at-risk patients is necessary to implement appropriate preventive strategies. RELEVANCE TO CLINICAL PRACTICE: Patients who are difficult to sedate in the ICU may develop psychological disorders upon discharge, which may negatively affect their recovery. The prevention of DS and the early detection of psychological disorders are essential to minimize its subsequent impact.

Neutrophil-to-lymphocyte ratio and mesenteric ischemia: can it predict the etiology of mesenteric ischemic at computed tomography?

OBJECTIVES: To assess the usefulness of the neutrophil-to-lymphocyte ratio (NLR) as a predictive factor of acute mesenteric ischemia (AMI) in patients presenting at the emergency department (ED) with acute abdominal pain. METHODS: This is a retrospective case-control study of patients older than 16 years admitted to the ED with acute abdominal pain with CT and histologic confirmation. The study group corresponded to patients with abdominal CT with radiological signs of AMI. The control group corresponded to patients with non-AMI findings in abdominal CT. Association measurements of NLR with radiological signs were compared with a paired-sample t test, and multivariate regression performed to analyze potential correlations. To assess the diagnosis capacity of NLR, ROC curves were calculated. RESULTS: A total of 61 patients were included (32 cases and 29 controls). The cases of AMI showed higher mortality (43.8% vs 6.9%, p < 0.01) and higher NLR on the limit of statistical significance (13.8 vs 8.7, p = 0.053). Patients with AMI due to occlusion of the superior mesenteric artery (SMA) showed a higher NLR (8.3 vs 22.3, p < 0.001). The area under the curve (AUC) of the NLR for AMI due to occlusion of the SMA was 0.88 (95% CI 0.7-1.0, p = 0.001). No patient with NLR < 5 presented AMI due to occlusion of the SMA. An NLR of 12.8 showed a sensitivity of 92% and a specificity of 74% for AMI due to occlusion of SMA. CONCLUSIONS: The NLR is a useful parameter of AMI of arterial origin due to occlusion of the SMA; it can help the clinician to raise suspicion of this diagnosis and the interpreting radiologist in the acquisition protocol for the CT study and would alert for an early surgical treatment.

Is urgent CT angiography necessary in cases of acute lower gastrointestinal bleeding? / ¿Es necesario realizar una angiografía por tomografía computarizada urgente en la hemorragia digestiva baja aguda? Proyecto MAPAC-IMAGEN.

Acute lower gastrointestinal bleeding usually presents as hematochezia, rectal bleeding or melena and represents 1-2% of the medical appointments in the Emergency Services. Mortality reaches the 30-40% and it is highly related with the severity and associated comorbidity. Most clinical practice guidelines include colonoscopy at some point in the diagnostic and therapeutic process (urgent for severe cases and ambulatory for mild ones) and look for predictors of severity. In the last years, there have been numerous studies where is clear the relevance and complementarity of advanced diagnostic imaging techniques, gradually incorporated as an alternative or second step in severe cases. Therefore, we have made a review of current scientific evidence to establish a clinical prediction rule for optimal indication of CT angiography in these patients. However, future studies providing greater robustness and level of evidence are necessary.

Routine abdominal X-rays in the emergency department: a thing of the past?

The large number of abdominal X-ray examinations done in the emergency department is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most of these examinations have normal or nonspecific findings, bringing into question the appropriateness of these examinations. Abdominal X-ray examinations are usually considered a routine procedure or even a "defensive" screening tool, whose real usefulness is unknown. For more than 30 years, the scientific literature has been recommending a reduction in both the number of examinations and the number of projections obtained in each examination to reduce the dose of radiation, unnecessary inconvenience for patients, and costs. Radiologists and clinicians need to know the important limitations of abdominal X-rays in the diagnostic management of acute abdomen and restrict the use of this technique accordingly. This requires the correct clinical selection of patients that can benefit from this examination, which would allow better use of alternative techniques with better diagnostic yield, such as ultrasonography or computed tomography.

Checklist: Neck computed tomography in non-traumatic emergencies.

Patients attending the emergency department (ED) with cervical inflammatory/infectious symptoms or presenting masses that may involve the aerodigestive tract or vascular structures require a contrast-enhanced computed tomography (CT) scan of the neck. Its radiological interpretation is hampered by the anatomical complexity and pathophysiological interrelationship between the different component systems in a relatively small area. Recent studies propose a systematic evaluation of the cervical structures, using a 7-item checklist, to correctly identify the pathology and detect incidental findings that may interfere with patient management. As a conclusion, the aim of this paper is to review CT findings in non-traumatic pathology of the neck in the ED, highlighting the importance of a systematic approach in its interpretation and synthesis of a structured, complete, and concise radiological report.

[Corpus cavernosum fracture: the ultrasound in the emergency diagnosis]. / Fractura de cuerpo cavernoso: la ecografía en el diagnóstico de urgencia.

OBJECTIVE: The main objective of this work is to study usefulness of ultrasound (US) for the emergency diagnosis of the penile fracture. MATERIAL AND METHODS: We reviewed all the penile US studies registered in our Emergency Department between July 2007 and August 2009 with suspicion of a corpus cavernosum fracture. We compared US findings (subcutaneous haematoma, peri-albuginea haematoma, albuginea rupture and Bucks fascia rupture), and the clinical progress, with those of the surgery. We studied sensitivity, specificity, positive predictive value and negative predictive value of US in the diagnosis of rupture of the tunica albuginea. The epidemiological data of all the cases reviewed were collected. RESULTS: Twelve patients with a mean age of 37.8 years were reviewed. The most common cause of injury was sexual intercourse. A subcutaneous haematoma was found in nine patients, a peri-albuginea hematoma in eleven of the cases, and an albuginea rupture was seen in six of them. We found no Bucks fascia rupture. Seven patients underwent surgical treatment and in the remaining five patients, treatment was conservative. Clinical progress was good in all cases. US, as an emergency test to diagnose albuginea fracture gave 0.83 sensitivity, 1 specificity, 1 positive predictive value and 0.83 negative predictive value. CONCLUSION: We believe that US is a useful procedure in the diagnosis of acute penile fracture and that it could be proposed as the diagnostic method of choice to confirm the clinical suspicion of penile fracture. Identifying the exact site of a tear in the tunica albuginea facilitates the surgical procedure.

Cervical spine trauma.

Cervical spine trauma encompasses a wide of injuries, ranging from stable, minor lesions to unstable, complex lesions that can lead to neurologic sequelae or vascular involvement. The Canadian C-Spine Rule and the NEXUS criteria aim to identify individuals with a low risk of cervical spine trauma who can safely forgo imaging tests. In high-risk patients, an imaging test is indicated. In adult patients the imaging test of choice is multidetector computed tomography. Complementary imaging tests such as CT angiography of the supra-aortic vessels and/or magnetic resonance imaging are occasionally necessary. It can be challenging for radiologists to diagnose and classify these lesions, because some of them can be subtle and difficult to detect. This paper aims to describe the most important imaging findings and the most widely used classification systems.

Water network cost optimization in a paper mill based on a new library of mathematical models.

The increasing costs associated with water supply and the disposal of wastewater has stimulated industries to seek more efficient water management systems. Mathematical modelling and simulation can be a very valuable tool for the study of the multiple alternatives available whilst assessing optimum solutions for water management in industry. This study introduces a new steady state model library able to reproduce industrial water circuits. It has been implemented in a novel software framework for the representation, simulation and optimization of industrial water networks. A water circuit representing a paper mill has been modelled and simulated showing the capability to reproduce real case studies. Alternative scenarios for the water network have also been tested to assess the capability of the models to optimize water circuits minimizing total cost.

Automatic characterisation of primary, secondary and mixed sludge inflow in terms of the mathematical generalised sludge digester model.

This paper presents the characterisation procedure of different types of sludge generated in a wastewater treatment plant to be reproduced in a mathematical model of the sludge digestion process. The automatic calibration method used is based on an optimisation problem and uses a set of mathematical equations related to the a priori knowledge of the sludge composition, the experimental measurements applied to the real sludge, and the definition of the model components. In this work, the potential of the characterisation methodology is shown by means of a real example, taking into account that sludge is a very complex matter to characterise and that the models for digestion also have a considerable number of model components. The results obtained suit both the previously reported characteristics of the primary, secondary and mixed sludge, and the experimental measurements specially done for this work. These three types of sludge have been successfully characterised to be used in complex mathematical models.

[Multidetector computed tomography as the first diagnostic option for acute lower digestive tract bleeding in the Emergency Department]. / La tomografía computarizada multidetector como primera opción diagnóstica en la hemorragia digestiva baja aguda en Urgencias.

The wide availability, speed, safety, and diagnostic accuracy of multidetector computed tomography (MDCT) make it the first-line diagnostic tool in the study of acute bleeding of the lower digestive tract. The use of MDCT after the initial stabilization of the patient makes it possible to identify active bleeding and to determine its origin and possible cause, even when bleeding has stopped. MDCT provides information that is key to selecting the most appropriate treatment option: colonoscopy, embolization, surgery, or clinical follow-up. MDCT orients the surgical or endovascular intervention, minimizing the time, risks, and doses of radiation and of contrast agents involved in the intervention and avoiding "blind" resections associated with greater morbimortality. Although the active presence of radiologists in the Emergency Department involves some disadvantages in scheduling, it also places radiologists in a privileged position in their relations with other techniques and professionals involved in the management of acute lower digestive tract bleeding.

[Is H1N1 flu different from seasonal flu on initial plain chest films?]. / Gripe A ¿diferente de la gripe estacional?

OBJECTIVES: To determine whether there are differences in the findings on the initial plain chest films of patients with H1N1 influenza and those of patients with flu symptoms during the flu season. MATERIAL AND METHODS: All patients underwent plain-film chest radiography in the Emergency Department for flu symptoms; 95 patients had H1N1 influenza confirmed between July 2009 and December 2009 and 95 patients were attended for symptoms of seasonal flu in January 2009. We analyzed the views obtained, the distribution and location of the radiologic findings, and patients' age, sex, and previous disease. RESULTS: Patients with H1N1 influenza were younger than those with seasonal flu symptoms (mean 40.2 vs 50.9 years; p<0.001) and fewer had prior disease (48 vs. 63; p<0.001). Plain films were acquired with patients in the standing position in 75 patients in the H1N1 group and in 77 in the seasonal flu group; pathological findings were present in nearly 50% of the patients in each group. The most common findings in the H1N1 group were multifocal patchy consolidations (41.2%; p<0.001) and peribronchial-vascular opacities (16.3%), whereas in the seasonal flu group the most common finding was consolidation in a single lobe (43.9%). CONCLUSION: We found significant differences between the radiologic findings of patients with H1N1 influenza (severe) and those of patients with symptoms of flu during the flu season: the incidence of multifocal patchy consolidation was greater in H1N1 patients and H1N1 patients were younger.

Online monitoring of OUR, K(L)a and OTE indicators: practical implementation in full-scale industrial WWTPs.

Based on on/off aeration strategies, this paper describes all the steps involved in the development and implementation of three identification algorithms aimed at monitoring the oxygen uptake rate (OUR), the oxygen mass-transfer coefficient (K(L)a), and oxygen transfer efficiency (OTE) in aerated biological reactors. Firstly, a detailed explanation of the theoretical background behind every algorithm is given. In addition, practical issues have also been taken into account in order to guarantee the quality of estimations. Finally, the three algorithms have been implemented and validated in a full-scale industrial wastewater treatment plant with satisfactory results. Although short-term noise has been observed in the estimated data (especially at high OURs), the medium and long-term data trajectories have been correctly reproduced.

Traumatic Injury of the Petrous Part of the Temporal Bone: Keys for Reporting a Complex Diagnosis. / Patología traumática de peñascos, un diagnóstico complejo. Claves para el informe.

Fractures of the petrous part of the temporal bone are a common lesion of the base of the skull; most of these fractures result from high-energy trauma. In patients with multiple trauma, these injuries can be detected on CT scans of the head and neck, where the direct and indirect signs are usually sufficient to establish the diagnosis. It is important to these fractures because the temporal bone has critical structures and the complexity of this region increases the risk of error unless special care is taken. This article reviews the key anatomical points, the systematization of the imaging findings, and the classifications used for temporal bone fracture. We emphasize the usefulness of identifying and describing the findings in relation to important structures in this region, of looking for unseen fractures suspected through indirect signs, and of identifying anatomical structures that can simulate fractures. We point out that the classical classifications of these fractures are less useful, although they continue to be used for treatment decisions.

[Consensus document for sepsis code implementation and development in the Community of Madrid]. / Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid.

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.

A new plant-wide modelling methodology for WWTPs.

This paper presents a new plant-wide modelling methodology for describing the dynamic behaviour of water and sludge lines in WWTPs. The methodology is based on selecting the set of process transformations needed for each specific WWTP to model all unit-process elements in the entire plant. This "transformation-based" approach, in comparison with the conventional "process-based" approach, does not require the development of specific transformers to interface the resulting unit-process models, facilitates the mass and charge continuity throughout the whole plant and is flexible enough to construct models tailored for each plant under study. As an illustrative example, a plant-wide model for a WWTP that includes carbon removal and anaerobic digestion has been constructed, and the main advantages of the proposed methodology for integrated modelling have been demonstrated. As a final consequence, this paper proposes a rewriting of the existing unit-process models according to the new standard transformation-based approach for integrated modelling purposes.

Mathematical modelling of autothermal thermophilic aerobic digesters.

This paper presents a new mathematical model for Autothermal Thermophilic Aerobic Digesters. The reactor has been modelled as two completely mixed volumes to separately predict the behaviour of the liquid and gaseous phases as well as the interrelation between them. The model includes biochemical transformations based on the standard Activated Sludge Models of IWA, as well as physico-chemical transformations associated with the chemical equilibria and the mass transfer between the liquid and the gaseous phases similar to those proposed in the ADM1 of IWA. An energy balance has also been included in the model in order to predict the temperature of the system. This thermal balance takes into account all those biochemical and physico-chemical transformations that entail the most relevant heat interchanges. Reactor performance has been explored by simulation in two different scenarios: in the first where it acts as the initial stage in a Dual system, and in the second where it acts as a single-stage treatment. Each scenario enabled the identification of the relevance of the different parameters.

[Importance of ultrapure dialysis liquid in response to the treatment of renal anaemia with darbepoetin in patients receiving haemodialysis]. / Importancia del líquido de diálisis ultrapuro en la respuesta al tratamiento de la anemia renal con darbepoetina en el paciente en hemodiálisis.

Chronic inflammatory diseases and infections are a major cause of hyporesponse to erythropoiesis-stimulating factors. We conducted this prospective study in 107 patients in haemodialysis with dialysis liquid that was potentially contaminated from a bacteriological perspective in order to test the hypothesis that ultrapure dialysis liquid can improve the response to treatment with darbepoetin and reduce inflammatory markers. These patients had to have been stable in the last 8 weeks in relation to haemoglobin level and the administered dose of darbepoetin. Two filters (one of hydrophilic nylon and another of polysulfone) were added to the water treatment process, the first one prior to distribution ring output and the second before the dialyser. The patients were evaluated for 12 months. The dosage of darbepoetin was varied to maintain haemoglobin levels ranging from 11 to 14 g/dl. We measured resistance to the erythropoiesis-stimulating factor, defined as the quotient between weekly dose of darbepoetin and haemoglobin levels, baseline and every two months, the baseline and monthly endotoxin count and reactive protein C at baseline and every 6 months. 94 patients completed the study. The resistance index fell significantly during follow-up (p<0.001) and was measurable from the second month on. Haemoglobin levels remained within the established margins with a 34% reduction in the weekly dose of darbepoetin at the end of the follow-up period. Both reactive protein C and the endotoxin count were significantly reduced (p<0.001) compared to baseline after 6 and 12 months. To conclude, the bacteriological purity of the dialysis liquid reduces inflammatory markers in patients receiving haemodialysis, improving the response to treatment with darbepoetin in renal anaemia.