Carles Luaces Cubells

Características epidemiológicas de las tentativas de suicidio en adolescentes atendidos en Urgencias

INTRODUCTION Suicide attempt in adolescents is a major global health problem. In order to prevent them, the risks factors need to be identified. The present study evaluates the clinical and epidemiological aspects of adolescent patients after attempted suicide, who were seen in an emergency department. MATERIALS AND METHODS Description of retrospective study of patients younger than 18 years who visited emergency department unit after a suicide attempt, during the period from 2008 to 2012. RESULTS A total of 241 patients were included, of whom 203 were female. The median age of the patients was 15.6 years. Psiquiatric history was present in 65.1% of the patients. The most frequent suicide mechanism was drug overdose (94.2%). Attempted suicide ideation was more common in males and in patients with previous attempts, and were also more related to sequels. Moreover, patients with an overdose were associated with psychiatric history and clinical toxicity. CONCLUSIONS Patients with any of the following characteristics; male, psychiatric history, a history of previous suicide attempts and/or clinical toxicity at the time of the visit in the emergency center, were more associated suicidal ideation before the attempt. Therefore, they had greater severity and risk repeating the attempt. They require a careful psychiatric evaluation and close monitoring.

Criterios de riesgo de bacteriemia en el paciente oncológico neutropénico febril pediátrico

ResumenIntroducciónLos pacientes oncológicos con neutropenia febril no constituyen un grupo de riesgo homogéneo. Algunos investigadores han propuesto que los pacientes oncológicos con neutropenia febril que reúnen criterios de bajo riesgo de bacteriemia pueden ser tributarios de tratamiento antibiótico domiciliario. Los objetivos son: conocer la incidencia de bacteriemia en nuestra población de pacientes oncológicos febriles y determinar la existencia de criterios de riesgo de bacteriemia de forma que pueda considerarse el manejo extrahospitalario en pacientes seleccionados.Material y métodosSe efectúa una revisión de las historias clínicas de los enfermos con patología hematooncológica ingresados en nuestro centro con fiebre y neutropenia, durante el año 2002.ResultadosSe describen un total de 62 episodios febriles en 30 pacientes. En 24 casos los pacientes presentaban un tumor de origen hematológico y 38 un tumor sólido. Se definen como criterios de alto riesgo; ser menor de 1 año, escasa respuesta medular, quimioterapia en los 10 días previos, neutropenia de rápida evolución, leucemia en recidiva, tumor sólido no controlado y enfermedad cardíaca o renal asociada. En función del número de criterios de riesgo de cada paciente, se observa que los pacientes que tienen dos o menos criterios de riesgo tienen una incidencia de bacteriemia del 6,7% (1/16), mientras que los que tienen tres o más tienen una incidencia de bacteriemia del 32,6% (15/46) con p<0,05.ConclusionesLa incidencia de bacteriemia en nuestra seríe es algo mayor que la bibliografía con predominio de bacilos grammegativos; la probabilidad de presentar bacteriemia se incrementa de forma proporcional a los criterios de riesgo individuales, y la existencia de subgrupos de pacientes de menor riesgo posibilita que puedan definirse unos criterios de selección para el manejo extrahospitalario de estos pacientes.AbstractIntroductionCancer patients with febrile neutropenia are not a homogeneous group with respect to risk of bacterial infections. Some authors have proposed that febrile cancer patients with low risk factors of bacteraemia could be managed at home with domiciliary antibiotic treatment. The objectives are: to determine the incidence of bacteraemia in our cancer patients who have febrile neutropenia; and to identify the low-risk factors so that the patients can be managed at home using domiciliary antibiotic treatment.Material and methodsClinical review of paediatric haemato-oncology disease admitted to our hospital in 2002 suffering from febrile neutropenia.ResultsWe describe a total of 62 episodes of febrile neutropenia in 30 patients; 24 episodes in haematology patients and 38 episodes in oncology patients. High-risk criteria are age <1 year, poor bone-marrow recovery, chemotherapy within 10 days of the episode, rapid fast neutropenia, leukaemia in relapse, uncontrolled solid cancer, and cardiac or nephrology disease. Based on the number of risk-factors, patients with two or less risk-factors have an incidence of bacteraemia of 6.7% (1/16) and patients with three or more risk factors have an incidence of bacteraemia of 32.6% (15/46); p<0.05.ConclusionsIncidence of bacteraemia is similar to the reviewed literature; probability of bacteraemia increases with the number of individual risk factors, and patients with low risk of bacteraemia could be managed on an outpatient basis using domiciliary antibiotic treatment.INTRODUCTION Cancer patients with febrile neutropenia are not a homogeneous group with respect to risk of bacterial infections. Some authors have proposed that febrile cancer patients with low risk factors of bacteraemia could be managed at home with domiciliary antibiotic treatment. The objectives are: to determine the incidence of bacteraemia in our cancer patients who have febrile neutropenia; and to identify the low-risk factors so that the patients can be managed at home using domiciliary antibiotic treatment. MATERIAL AND METHODS Clinical review of paediatric haemato-oncology disease admitted to our hospital in 2002 suffering from febrile neutropenia. RESULTS We describe a total of 62 episodes of febrile neutropenia in 30 patients; 24 episodes in haematology patients and 38 episodes in oncology patients. High-risk criteria are age <1 year, poor bone-marrow recovery, chemotherapy within 10 days of the episode, rapid fast neutropenia, leukaemia in relapse, uncontrolled solid cancer, and cardiac or nephrology disease. Based on the number of risk-factors, patients with two or less risk-factors have an incidence of bacteraemia of 6.7% (1/16) and patients with three or more risk factors have an incidence of bacteraemia of 32.6% (15/46); p<0.05. CONCLUSIONS Incidence of bacteraemia is similar to the reviewed literature; probability of bacteraemia increases with the number of individual risk factors, and patients with low risk of bacteraemia could be managed on an outpatient basis using domiciliary antibiotic treatment.

Utilidad de las técnicas de cribado de tóxicos en orina solicitadas desde el servicio de urgencias de un hospital pediátrico

OBJECTIVE To describe the situations in which urine drug screening is used in a Paediatric Emergency Department (ED). An analysis is also made on its potential usefulness on whether it changes the patient management, and if the results are confirmed by using specific techniques. METHODOLOGY A retrospective study was conducted on patients under the age of 18 attended in the ED during 2014 and in whom urine drug screening was requested. Depending on the potential capacity of the screening result to change patient management, two groups were defined (potentially useful and not potentially useful). RESULTS Urine drug screening was performed on a total of 161 patients. The screening was considered not to be potentially useful in 87 (54.0%). This was because the clinical history already explained the symptoms the patient had in 55 (34.1%) patients, in 29 (18.0%) because the patient was asymptomatic, and in 3 (1.9%) because the suspected drug was not detectable in the screening. The drug screening results changed the patient management in 5 (3.1%) cases. A toxic substance was detected in 44 (27.3%). Two out of the 44 that were positive (2.1%) were re-tested by specific techniques, and presence of the toxic substance was ruled out in both of them (false positives). CONCLUSIONS Most of the drug screening tests are not justified, and it is very infrequent that they change patient management. It is very rare that the results are confirmed using more specific methods. Urine drug screening tests should be restricted to particular cases and if the result has legal implications, or if the patient denies using the drug, it should be followed by a specific toxicological study to provide a conclusive result.

Observación clínica: una alternativa segura a la radiología en lactantes con traumatismo craneoencefálico leve

OBJECTIVE The protocol for the management of mild cranioencephalic trauma in the emergency department was changed in July 2013. The principal innovation was the replacement of systematic X-ray in infants with clinical observation. The aims of this study were to determine whether there was, 1) a reduction in the ability to detect traumatic brain injury (TBI) in the initial visit to Emergency, and 2) a change in the number of requests for imaging tests and hospital admissions. METHODOLOGY This was a retrospective, descriptive, observational study. Two periods were established for the study: Period 1 (1/11/2011-30/10/2012), prior to the implementing of the new protocol, and Period 2 (1/11/2013-30/10/2014), following its implementation. The study included visits to the emergency department by children≤2 years old for mild cranioencephalic trauma (Glasgow Scale modified for infants≥14) of ≤24hours onset. RESULTS A total of 1,543 cases were included, of which 807 were from Period 1 and 736 from Period 2. No significant differences were observed as regards sex, age, mechanism, or risk of TBI. More cranial fractures were detected in Period 1 than in Period 2 (4.3% vs 0.5%; P<.001), without significant changes in the detection of TBI (0.4% vs 0.3%; P=1). However, there were more cranial X-rays (49.7% vs 2.7%; P<.001) and more ultrasounds (2.1% vs 0.4%; P<.001) carried out, and also fewer hospital admissions (8.3% vs 3.1%; P<.001). There were no significant differences in the number of computerised tomography scans carried out (2% vs 3%; P=.203). CONCLUSIONS The use of clinical observation as an alternative to cranial radiography leads to a reduction in the number of imaging tests and hospital admissions of infants with mild cranioencephalic trauma, without any reduction in the reliability of detecting TBI. This option helps to lower the exposure radiation by the patient, and is also a more rational use of hospital resources.

Hiperfrecuentación en las urgencias pediátricas. Respuesta del autor

En primer lugar agradecer a Herranz Jordán y Jiménez García1 su interés en la lectura de nuestra editorial. Indudablemente compartimos muchas de sus reflexiones. Cuando manifestamos que no tenemos ninguna duda sobre la «profesionalidad y capacidad de nuestros compañeros de atención primaria» y apuntamos a «la falta de recursos globales en el marco de la atención primaria con especial énfasis en el déficit de pediatras» como elementos clave del problema, estamos poniendo el foco con mayor énfasis en las causas de tipo organizativo y que son en gran parte responsabilidad de la administración y/o del sistema sanitario. En esta línea también apuntamos que la enorme dificultad del pediatra de primaria para disponer habitualmente de unos medios diagnósticos apropiados condiciona, en muchas ocasiones, la inevitable derivación al centro hospitalario solicitada por el propio profesional o de forma espontánea por la propia familia. Es indudable y en esto también coincidimos plenamente con Herranz Jordán y Jiménez García1 que la solución no es sencilla y atañe a todos los actores implicados. En el informe de Álvarez de Laviada Mulero et al.2 que citan los autores de la carta, se describen certera y exhaustivamente factores que pueden influir en la excesiva demanda espontánea que acude a los diversos dispositivos asistenciales. Factores que en dicho informe se distribuyen a partes iguales entre los usuarios por un lado y los profesionales y la organización por otro. También en el citado informe se incluyen unas propuestas y recomendaciones. En nuestra opinión entre las propuestas a la administración además de la campaña educativa sobre el uso racional de los recursos sanitarios es fundamental que esta regule también el acceso a los recursos con medidas que limiten de algún modo los flujos indiscriminados de pacientes evitando un uso inadecuado y reiterado de los dispositivos sanitarios basados en un acceso libre y aparentemente gratuito. Consecuencia de estos flujos desordenados es que el incremento de la oferta de dispositivos asistenciales solo consigue un aumento de la demanda sin que en ningún caso se racionalice su uso. Por supuesto existe también un margen de mejora por parte de los propios dispositivos sanitarios (centros de asistencia primaria, hospitales,. . .) y de los profesionales que indudablemente debe ser asumido; entre otras cosas y también como citábamos en nuestro manuscrito, ofrecer asistencia en aquellos tramos horarios y días donde existe una demanda de atención espontánea o no pero propia de su nivel asistencial contando, por supuesto, con la dotación y organización externa e interna necesarias evitando así la «obligada visita» a un centro hospitalario. Indudablemente las tardes tienen mayor presión asistencial y dificultan la vida familiar hecho que también lo saben y bien, los pediatras de urgencias hospitalarios a los que en su horario se incluyen de forma habitual mañanas, tardes, noches y los festivos correspondientes sin que ello suponga tampoco ninguna compensación económica o de otro tipo visitando en muchos casos, una enfermedad, y esto es sobradamente conocido, enfermedad impropia de ser atendida, como ya hemos dicho, en un centro hospitalario. Sin embargo y a nuestro entender, las acciones de mejora difícilmente llegarán en algún momento a ser suficientes si con las recomendaciones y propuestas necesarias de ordenar y adecuar los flujos de pacientes no somos capaces que las consultas del usuario se produzcan cuando sea necesario y en el lugar apropiado. Si no se consigue este objetivo de adecuación de los flujos de pacientes, únicamente iremos poniendo «parches» al constante incremento de la demanda. Para ello, como hemos comentado, debe jugar un papel fundamental la administración y/o el sistema sanitario. De hecho y como menciona la carta de Herranz Jordán y Jiménez García1 puede observarse como las acciones encaminadas a buscar la solución al problema y propuestas por el sistema sanitario se centran en «facilitar» el acceso al paciente (turnos por la tarde, facilidad para la cita previa, nuevos hospitales públicos,. . .) y esto es correcto si de igual modo y paralelamente se dota por parte del sistema de los recursos adecuados a los profesionales que son quienes van a asumir esas medidas facilitadoras para el paciente. Por supuesto, la administración y/o sistema como gestor y administrador principal de recursos debe ser capaz de promover alguna medida para conseguir de los usuarios una utilización más justa y racional del sistema sanitario. Ello no debe significar en ningún caso una limitación del paciente a su innegable derecho a una atención sanitaria pública y de la mayor calidad.

Impacto de un programa de formación de catástrofes en el personal sanitario

OBJECTIVES The aim of this study is to evaluate the effectiveness of a disaster preparedness training program in a Paediatric Emergency Department (PED). METHODS A quasi-experimental study was conducted using an anonymous questionnaire that was distributed to health care providers of a PED in a tertiary paediatric hospital. The questions concerned the disaster plan (DP), including theoretical and practical aspects. Questionnaires were distributed and completed in January 2014 (period 1) and November 2014 (period 2). The disaster training program includes theoretical and practical sessions. RESULTS A total of 110 questionnaires were collected in period 1, and 80 in period 2. Almost three-quarters (71.3%) of PED staff attended the theoretical sessions, and 43.8% attended the practical sessions. The application of this training program significantly improved knowledge about the DP, but no improvement was observed in the practical questions. PED staff felt more prepared to face a disaster after the training program (15.5% vs. 41.8%, P<.001). CONCLUSIONS The training program improved some knowledge about the disaster plan, but it has not improved responses in practical situations, which may be due to the low attendance at practical sessions and the time between the training program and the questionnaires.