Appropriateness of emergency department visits in a Portuguese university hospital

STUDY OBJECTIVE: There are no studies in Portugal supporting a common claim that most emergency department visits are inappropriate. The aim of this study was to determine the prevalence of and to evaluate factors associated with an appropriate ED visit in a major public hospital. METHODS: A cross-sectional prospective study was performed at a public university hospital ED. Data for demographic variables, duration of complaint, transfer from other medical sources, and previous medical care for the same complaints were collected by interviewing all patients who arrived at the ED within a consecutive period of at least 24 hours. Data for diagnostic tests, treatment performed, and final patient destination were collected by triage records review. An appropriate ED visit was defined by explicit criteria: interhospital transfer, patient death at the ED, hospitalization, and diagnostic tests or treatments performed. RESULTS: The study included 5,818 adult patients. The prevalence of an appropriate ED visit, by use of our criteria, was 68.7%. Sex was an effect modifier. According to this study, determinants of an appropriate visit for men and women were age 60 years or older and complaints of 24 hours or less and in women but not in men, retired from work and with arrival between midnight and 8 AM. CONCLUSIONS: In a university hospital in Oporto, the majority of ED visits were appropriate according to explicit criteria. Some variables may be associated with appropriateness of ED visits. A duration of the complaint 24 hours or less along with an arrival between midnight and 8 AM in women and age 60 years or older in men were the most important determinants.     

Chronic active hepatitis in patients with and without hepatitis B surface antigenemia

Summary This study was designed to compare the clinical and immunological characteristics of the hepatitis B surface antigen (HB_SAg)-positive and HB_SAg-negative (cryptogenic) forms of chronic active hepatitis. The data of 48 patients with chronic active hepatitis, 24 with persistent HB_S antigenemia and 24 without HB_SAg, were analysed. HB_SAg was detected by counter-immunoelectrophoresis and radioimmunoassay. The clinical features, biochemical liver function tests, immunoglobulins, complement C3, autoantibodies, and cell-mediated immunoreactivity of the two forms of the disease were compared. Cirrhosis was found to occur more frequently at the time of diagnosis in the HB_SAg-negative group, and the serum alkaline phosphatase level was raised significantly compared to the HB_SAg-positive form. The elevation of the IgG level was greater in the cryptogenic form, but the difference was not statistically significant compared to the HB_SAg-positive patients. There was a marked difference in the frequency of the mitochondrial antibodies, but not of the antinuclear factor and other autoantibody-like serum factors. Lymphoblastic transformation revealed a similar diminution in response to phytohaemagglutinin stimulation in both groups of patients compared to the normal controls. An increase of the³H-thymidine incorporation was seen after stimulation with human liver mitochondrial antigen, and leukocyte migration inhibition could be observed with this antigen in both forms of chronic active hepatitis.

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Aktive chronische Hepatitis in Patienten mit und ohne Hepatitis-B-Oberflächenantigenämie — ein klinischer und immunologischer Vergleich

Zusammenfassung Das Studium wurde durchgeführt, um klinische und immunologische Charakteristika des Hepatitis-B-Oberflächen-Antigens (HB_SAg)-positive und -negative (kryptogene Form) Befunde der chronischen aktiven Hepatitis zu vergleichen. Die Angaben von 48 Patienten mit chronischer aktiver Hepatitis, davon 24 mit persistierender HB_S-Antigenämie und 24 ohne HB-Befund, wurden analysiert. Die HB_S-Antigenämie wurde mit Hilfe von Gegenstromelektrophorese und Radioimmunassay nachgewiesen. Das klinische Bild sowie die Laborbefunde (Leberfunktionsteste, Immunuglobuline, Komplement-C3, Autoantikörper und zellulär ausgelöste Immunantwort der beiden Krankheitsformen) wurden vergliche. Es wurde gefunden, daß eine Zirrhose häufiger in der HB_S-negativen Gruppe auftrat und der alkalische Serumphosphatase-Spiegel signifikant anstieg. Die Werte des IgG-Spiegel lagen bei den kryptogenen Formen höher, ohne einen statistisch signifikanten Unterschied im Vergleich zu den HB_S-positiven Patienten zu ergeben. Es bestand ein deutlicher Unterschied im Auftreten von mitochondrialen Antikörper. Dies galt jedoch nicht für Antinuklearfaktoren und andere Antikörper ähnlicher Serumfaktoren. Die lymphoblastentransformation ergab in beiden Gruppen eine ähnliche Reaktionseinschränkung gegenüber der Phytohämagglutinin-Stimulierung in beiden Patientengruppen, verglichen mit normalen Kontrollen. Ein Anstieg der³H-Thymidin-Inkorporation wurde nach einer Stimulierung mit humanem mitochondrialen Antigen der Leber beobachtet. Das gleiche galt auch für beiden Formen der chronischen aktiven Hepatitis mit demselben Antigen für die Hemmung der Leukozytenmigration.

     

Intracarotid norepinephrine infusions inhibit ventilation in goats.

Plasma norepinephrine (NE) increases from rest to exercise during normoxic exercise, and significantly more during hypoxic exercise in goats. To determine carotid body (CB) mediated effects of increased NE on ventilatory control, we investigated ventilatory responses to intracarotid NE infusions in awake, resting goats. NE was infused (0.5-5.0 micrograms.kg-1 x min-1, 2-3 min) into either a CB intact or contralateral CB-denervated carotid artery in both normoxia and hypoxia (FIO2. = 0.11). PRE-infusion measurements of arterial blood gases, blood pressure and pulmonary ventilation (VI) were compared with values 30-45 sec after beginning NE infusions at 1.0 micrograms.kg-1 x min-1. On the CB-intact side, NE infusions decreased VI by an average of 43% (P < 0.05) and increased PaCO2 4.0 +/- 0.3 mmHg (P < 0.05); ventilatory inhibition preceded an increase in arterial blood pressure. NE infusions on the CB-denervated side had no significant effects on VI or PaCO2, but still increased blood pressure to the same level as infusions on the CB-intact side. In hypoxia, NE infusions on the intact side no longer inhibited VI. NE induced VI inhibition in normoxia was similar in magnitude and time course to dopamine induced VI inhibition. Experiments were repeated following administration the alpha-adrenergic receptor antagonist, phenoxybenzamine (1 mg.kg-1, i.v.) the beta-adrenergic receptor antagonist, propranolol (1 mg.kg-1, i.v.) and the D2-dopamine receptor antagonist, domperidone (1 mg.kg-1, i.v.). Phenoxybenzamine partially blocked NE induced ventilatory depression and domperidone blocked it, but propranolol had no effect. These data indicate that NE inhibits ventilation in goats via effects on carotid chemoreceptors. NE induced inhibition is independent of changes in blood pressure or baroreceptor feedback, and appears to involve both alpha-adrenergic and D2-dopaminergic receptors.     

Fecal lactoferrin, interleukin-1beta, and interleukin-8 are elevated in patients with severe Clostridium difficile colitis.

Twenty-two patients with Clostridium difficile colitis as determined by positive enzyme immunoassay for toxin A were evaluated for fecal inflammatory markers and their relationship to the severity of illness. Fourteen of 22 specimens were positive for fecal lactoferrin (FLF), with titers from 1:50 to 1:800. Nine of 10 stools tested had ratios of interleukin-1beta (IL-1beta) to IL-1 receptor antagonist (IL-1ra) of >0.01. Seventeen of 22 specimens also had elevated IL-8 concentrations, and 12 of 14 had elevated IL-1beta concentrations. A review of the 18 available patient records revealed that fecal IL-8 concentrations, IL-1beta/IL-1ra ratios, and FLF titers were significantly higher in patients with moderate to severe disease than in patients with mild disease. These findings suggest that the proinflammatory effects of C. difficile may directly influence clinical characteristics of human disease.     

Qualitative enzyme histochemistry and microanalysis reveals changes in ultrastructural distribution of calcium and calcium-activated ATPases after microwave irradiation of the medial habenula

The localization of calcium and calcium-activated ATPases was investigated electron microscopically in the medial habenula of mice after whole body irradiation with modulated microwaves. In non-irradiated animals calcium-containing precipitates were seen in different subcellular compartments and were often localized on the luminal side of membranes of synaptic vesicles in nerve terminals. At 1 h after 16-Hz modulated microwave irradiation, the number of synaptic vesicles containing calcium precipitates decreased, and reaction products appeared at new locations: in the synaptic clefts and on non-synaptic surfaces of the neuronal plasma membrane. This modified calcium distribution remained unchanged for 24 h following irradiation. Calcium-activated “ecto”-localized ATPase was detected as a punctuated-linear distribution of the reaction product outlining whole areas of glial and neuronal plasma membrane in the habenula of control animals. This pattern did not change on microwave irradiation. However, a quercetin-sensitive “endo”-localized Ca²⁺-ATPase activity appeared in some nerve terminals 24 h after irradiation. Thus, microwave irradiation can influence neuronal calcium homeostasis by inducing Ca²⁺ redistribution across the plasma membrane and by modifying Ca²⁺-ATPase activity. However, no direct correlation between these effects could be demonstrated by the present study. Received: 12 February 1996 / Revised, accepted: 11 April 1996     

Juvenile dermatomyositis. Clinical and epidemiologic experience

27 cases with a diagnosis of Juvenile Dermatomyositis were studied from a total of 1307 patients who suffered from connective tissue diseases; 19 of which met the diagnosis criteria of Bohan and Peters. Females were the most frequently affected. 52.63% of the cases presented the first symptoms between 5 and 9 years of age. Skin lesions, debility in inferior extremities and fever were the most frequent motives of consultation. The Aldolase and LDH were the muscular enzymes whose values increased in the majority of the cases. The electromyography was more sensible than the muscular biopsy in the diagnosis of the disease. We suggest that the epidemiologic and clinical characteristics found in our study should be taken into account for further accurate diagnosis of Juvenile Dermatomyositis in Venezuela.