Early and One-Year Stroke Case Fatality in Sao Paulo, Brazil: Applying the World Health Organization's Stroke STEPS

Case fatality rate is considered a main determinant of stroke mortality trends. We applied the World Health Organization's Stroke STEPS to identify case fatality rates in a community hospital in Brazil. We evaluated all patients with first-ever stroke seeking acute care at the hospital's emergency ward between April 2006 and December 2008 to verify early and late case fatality according to stroke subtype. We used years of formal education as a surrogate for socioeconomic status. Of 430 first-ever stroke events, 365 (84.9%) were ischemic and 65 (15.1%) were intracerebral hemorrhage. After 1 year, we adjudicated 108 deaths (86 ischemic; 22 hemorrhagic). Age-adjusted case fatality rates for ischemic stroke and intracerebral hemorrhage were 6.0% v 19.8% at 10 days, 10.6% v 22.1% at 28 days, 17.6% v 29.1% at 6 months, and 21.0% v 31.5% at 1 year. Illiteracy or no formal education was a predictor of death at 6 months (odds ratio [OR], 4.31; 95% confidence interval [CI] 1.34-13.91) and 1 year (OR, 4.21; 95% CI, 1.45-12.28) in patients with ischemic stroke, as well as at 6 months (OR, 3.19; 95% CI, 1.17-8.70) and 1 year (OR, 3.30; 95% CI, 1.30-8.45) for all stroke patients. Other variables, including previous cardiovascular risk factors and acute medical care, did not change this association to a statistically significant degree. In conclusion, case fatality, particularly up to 6 months, was higher in hemorrhagic stroke, and lack of formal education was associated with increased stroke mortality.

[A young child with acute abdomen and iron deficiency anemia]

The case of a 20 month-old girl that was admitted to the emergency ward because of worsening of her general condition in the setting of acute non-bloody gastroenteritis is reported. The clinical examination revealed signs of severe dehydration and a prominent tender abdomen. Laboratory evaluation showed leucocytosis, elevated C-reactive protein and severe hypochromic microcytic anemia. Abdominal X-ray revealed diffuse meteorism. The child underwent laparascopic evaluation. A perforated Meckel's diverticulum was found. Perforation and anemia due to occult bleeding are unusual presentations of Meckel's diverticulum. The differential diagnosis of children presenting with an acute abdomen with special focus on Meckel's diverticulum is discussed.

Management of fragility fractures in Switzerland: results of a nationwide survey

A nationwide survey was conducted in Switzerland to assess the quality level of osteoporosis management in patients aged 50 years or older presenting with a fragility fracture to the emergency ward of the participating hospitals. Eight centres recruited 4966 consecutive patients who presented with one or more fractures between 2004 and 2006. Of these, 3667 (2797 women, 73.8 years old and 870 men, 73.0 years old in average) were considered as having a fragility fracture and included in the survey. Included patients presented with a fracture of the upper limbs (30.7%), lower limbs (26.4%), axial skeleton (19.5%) or another localisation, including malleolar fractures (23.4%). Thirty-two percent reported one or more previous fractures during adulthood. Of the 2941 (80.2%) hospitalised women and men, only half returned home after discharge. During diagnostic workup, dual x-ray absorptiometry (DXA) measurement was performed in 31.4% of the patients only. Of those 46.0% had a T-score < or =-2.5 SD and 81.1% < or =-1.0 SD. Osteoporosis treatment rate increased from 26.3% before fracture to 46.9% after fracture in women and from 13.0% to 30.3% in men. However, only 24.0% of the women and 13.8% of the men were finally adequately treated with a bone active substance, generally an oral bisphosphonate, with or without calcium / vitamin D supplements. A positive history of previous fracture vs none increased the likelihood of getting treatment with a bone active substance (36.6 vs 17.9%, ? 18.7%, 95% CI 15.1 to 22.3, and 22.6 vs 9.9%, ? 12.7%, CI 7.3 to 18.5, in women and men, respectively). In Switzerland, osteoporosis remains underdiagnosed and undertreated in patients aged 50 years and older presenting with a fragility fracture.

Endstation Notfallstation: Perzeption und Rezeption des Begriffs «palliativer Patient» sowie Ansätze zur Verbesserung der interdisziplinären Zusammenarbeit – ein Survey unter notfallmedizinischem Personal auf einer Schweizer Notfallstation

Hintergrund: Wegen sich verändernder Strukturen im Spitalbereich sowie im Bereich der Hausarztabdeckung als auch infolge zunehmenden Drucks auf das Gesundheitssystem kommen mehr Patienten auf die Notfallstationen, die aufgrund ihrer Grunderkrankung und des fortgeschrittenen Krankheitsstadiums von einem palliativen Behandlungskonzept profitieren. Eine wesentliche Herausforderung ist hierbei bereits die Definition von «Palliative Care» (PC), sowie die Klärung, was genau die palliative Versorgung beinhaltet. Häufig vermischt wird der Terminus «Palliative Care» mit «End of life care». Die vorliegende Studie ist eine Standortbestimmung im Universitären Notfallzentrum des Inselspitals Bern (UNZ), das jährlich rund 32 400 Patienten versorgt. Ziel ist es, mehr über den Wissensstand und die persönliche Einstellung der Mitarbeiter zu palliativen Fragestellungen und speziell zum Begriff «Palliative Care» zu erhalten. Methodik: Die Mitarbeiter des Universitären Notfallzentrums des Inselspitals Bern (UNZ) wurden mittels einer Online-Umfrage durch eine spitalexterne Fachinstitution interviewt. Diese Befragung basiert auf einem Instrument [1], das in einer vergleichbaren Studie auf einer Notfallstation in den USA entwickelt und validiert wurde. Resultate: Von 154 Mitarbeitenden (Pflege und Ärzte) füllten 60 Mitarbeitende die Befragung vollständig aus, entsprechend einer Antwortrate von 39%. Die Definition von Palliative Care (von n=60) war sehr heterogen und konnte in sechs Themenbereiche eingeteilt werden. Bei den Fragen nach spezifischen Leistungsangeboten äusserten die Mitarbeitenden den Wunsch nach einem erleichterten Zugang zu bestehenden Patientendaten, nach einem 24-Stunden-Palliative-Care-Konsiliardienst und nach mehr Besprechungszeit für Fragestellungen der PC im klinischen Alltag. Schlussfolgerungen: Die heterogene Begriffsdefinition von «Palliative Care» bestätigt sich. Es besteht kein klares Vorgehen, und zudem lässt sich ein Zeitmangel für ausführliche Patientengespräche in palliativen Situationen im UNZ feststellen. Der Patientenwunsch oder Patientenverfügungen mit DNR/DNI-Prozedere stehen nicht im Widerspruch zu den persönlichen Wertvorstellungen der meisten Mitarbeitenden. Die 24-Stunden-Verfügbarkeit eines spezialisierten PC-Teams, das Erarbeiten von Guidelines und vermehrtes Training für PC würde von den UNZ-Mitarbeitenden begrüsst.

Une approche algorithmique des difficultés de raisonnement clinique : étude d’utilité, d’acceptabilité et de faisabilité

Résumé: INTRODUCTION Si les cliniciens enseignants détectent aisément les difficultés des apprenants, ils sont souvent peu outillés pour les étapes subséquentes, du diagnostic à la remédiation. Quoique des outils aient été développés pour les guider face aux difficultés de raisonnement clinique de leurs apprenants, ces outils peuvent être moins familiers des cliniciens et moins adaptés à des contextes de supervision ponctuelle et de soins aigus comme l’urgence. Nous avons donc développé une application algorithmique, à partir de la taxonomie d’Audétat et al. (2010), pour guider les cliniciens enseignants juste-à-temps face aux difficultés de raisonnement clinique. MÉTHODOLOGIE Une étude descriptive interprétative a été réalisée afin d’évaluer l’utilité, l’acceptabilité et la faisabilité d’utiliser cette application à l’urgence. Des entrevues semi-dirigées ont été menées auprès d’un échantillon de convenance de douze urgentistes, avant et après une période d’essai de l’outil de trois mois. RÉSULTATS L’application a été perçue comme particulièrement utile pour préciser les difficultés de raisonnement clinique des apprenants. Utiliser l’outil a été considérée acceptable et faisable en contexte d’urgence, en particulier grâce au format mobile. DISCUSSION Ces résultats suggèrent que l’outil peut être considéré utile pour faciliter l’identification des difficultés des apprenants, mais aussi pour offrir un soutien professoral accessible. Le format mobile et algorithmique semble avoir été un facteur facilitant, ce format étant déjà utilisé par les cliniciens pour consulter ponctuellement de l’information lors de la résolution de problèmes cliniques. CONCLUSION L’étude a démontré globalement une bonne utilité, acceptabilité et faisabilité de l’outil dans un contexte de supervision ponctuelle en soins aigus, ce qui soutient son utilisation par les cliniciens enseignants dans ce contexte. L’étude corrobore également l’intérêt d’un format mobile et algorithmique pour favoriser le transfert de connaissances en pédagogie médicale.

Ikääntyneen voimavaraistumista tukeva potilasohjaus päivystysosastolla kotiutumisen yhteydessä

Lisääntyvä ikääntyneiden määrä asettaa vaatimuksia terveydenhuollon järjestämiselle niin Suomessa kuin maailmanlaajuisestikin. Ikääntyneiden monialaiset ongelmat yhdessä perussairauksien kanssa muodostavat monimutkaisen kokonaisuuden, joka voi johtaa avun hakemiseen päivystyksestä. Ikääntyneiden hoidossa esiintyvät erityispiirteet, hoidettavien kognitiivisen toimintakyvyn heikkeneminen, lyhentyneet hoitoajat ja hoidon painopisteen siirtyminen kotiin vaativat hoitohenkilökuntaa yhä enenevässä määrin kiinnittämään huomiota potilasohjaukseen. Tutkimuksen tarkoituksena oli kuvata päivystysosastolta kotiutuvien ikääntyneiden ja sairaanhoitajien välisten ohjauskeskusteluiden rakennetta ja sisältöä. Tavoitteena oli tuottaa tietoa siitä, mitä voimavaraistumista tukevia piirteitä ja tiedon osa-alueita esiintyy ohjauskeskusteluissa. Tutkimuksen aineisto kerättiin ei-osallistuvalla havainnoinnilla videoimalla päivystysosastolta kotiutuvien ikääntyneiden ohjaustilanteita (n=22) syksyllä 2015. Osallistuneiden potilaiden keski-ikä oli 79 vuotta. Aineisto analysoitiin deduktiivisella sisällönanalyysilla. Ohjauskeskustelun rakenteesta etsittiin voimavaraistumista tukevia piirteitä ja sisältöä analysoitiin kuuden voimavaraistumista tukevan tiedon osa-alueen pohjalta (biofysiologinen, toiminnallinen, kokemuksellinen, sosiaalinen, eettinen ja taloudellinen). Ohjauskeskustelujen alussa ei asetettu ohjauksen tavoitteita tai arvioitu ikääntyneiden aikaisemman tiedon tasoa. Ohjauskeskustelut etenivät pääosin hoitajien määrittäminä. Ikääntyneet kysyivät vähemmän kysymyksiä ja heidän yksisanaisten puheenvuorojensa määrä oli suurempi kuin hoitajilla. Ikääntyneiden osallistumista ohjauskeskusteluun ei myöskään tuettu. Kysymyksen esitettyään hoitajat antoivat ikääntyneille mahdollisuuden vastata, mutta eivät varmistaneet, olivatko nämä ymmärtäneet ohjauksen. Ohjauskeskusteluiden sisältöä tarkasteltaessa tietoa ikääntyneille välitettiin pääasiassa biofysiologisen tiedon osa-alueelta (tietoa hoidosta ja oireista). Toiseksi eniten tietoa välitettiin ikääntyneille toiminnallisen tiedon osa-alueelta (liikkuminen ja kotona selviytyminen) ja sosiaalisen tiedon osa-alueelta (omaisten osallistuminen hoitoon). Taloudellisen tiedon osa-alue jäi aineistossa pieneksi. Tutkimuksen tulokset osoittavat tarvetta kiinnittää huomiota ohjauskeskusteluiden rakenteeseen ja sisältöön etenkin hoidettaessa ikääntyneitä, joilla on monitahoisia terveysongelmia. Tutkimuksesta saatavaa tietoa voidaan hyödyntää suunniteltaessa ja toteuttaessa ikääntyneiden potilasohjausta päivystyksessä sekä suunniteltaessa sairaanhoitajien potilasohjauskoulutusta.

Delay for admission of unstable hospitalized patients to intensive care unit: a need for a medical emergency team?

INTRODUCTION. Patients admitted in Intensive Care Unit (ICU) from general wards are more severe and have a higher mortality than those admitted from emergency department as reported [1]. The majority of them develop signs of instability (e.g. tachypnea, tachycardia, hypotension, decreased oxygen saturation and change in conscious state) several hours before ICU admission. Considering this fact and that in-hospital cardiac arrests and unexpected deaths are usually preceded by warning signs, immediate on site intervention by specialists may be effective. This gave an impulse to medical emergency team (MET) implementation, which has been shown to decrease cardiac arrest, morbidity and mortality in several hospitals. OBJECTIVES AND METHODS. In order to verify if the same was true in our hospital and to determine if there was a need for MET, we prospectively collected all non elective ICU admissions of already hospitalized patients (general wards) and of patients remaining more than 3 h in emergency department (considered hospitalized). Instability criteria leading to MET call correspond to those described in the literature. The delay between the development of one criterion and ICU admission was registered. RESULTS. During an observation period of 12 months, 321 patients with our MET criteria were admitted to ICU. 88 patients came from the emergency department, 115 from the surgical and 113 from the medical ward. 65% were male. The median age was 65 years (range 17-89). The delay fromMETcriteria development to ICU admission was higher than 8 h in 155 patients, with a median delay of 32 h and a range of 8.4 h to 10 days. For the remaining 166 patients, an early MET criterion was present up to 8 h (median delay 3 h) before ICU admission. These results are quite concordant with the data reported in the literature (ref 1-8). 122 patients presented signs of sepsis or septic shock, 70 patients a respiratory failure, 58 patients a cardiac emergency. Cardiac arrest represent 5% of our collective of patients. CONCLUSIONS.Similar to others observations, the majority of hospitalized patients admitted on emergency basis in our ICU have warning signs lasting for several hours. More than half of them were unstable for more than 8 h. This shows there is plenty of time for early acute management by dedicated and specialized team such as MET. However, further studies are required to determine if MET implementation can reduce in-hospital cardiac arrests and influence the morbidity, the length of stay and the mortality.

Alcohol-attributable injuries in admissions to a swiss emergency room--an analysis of the link between volume of drinking, drinking patterns, and preattendance drinking.

BACKGROUND: An association between alcohol consumption and injury is clearly established from volume of drinking, heavy episodic drinking (HED), and consumption before injury. Little is known, however, about how their interaction raises risk of injury and what combination of factors carries the highest risk. This study explores which of 11 specified groups of drinkers (a) are at high risk and (b) contribute most to alcohol-attributable injuries. METHODS: In all, 8,736 patients, of whom 5,077 were injured, admitted to the surgical ward of the emergency department of Lausanne University Hospital between January 1, 2003, and June 30, 2004, were screened for alcohol use. Eleven groups were constructed on the basis of usual patterns of intake and preattendance drinking. Odds ratios (ORs) comparing injured and noninjured were derived, and alcohol-attributable fractions of injuries were calculated from ORs and prevalence of exposure groups. RESULTS: Risk of injury increased with volume of drinking, HED, and preattendance drinking. For both sexes, the highest risk was associated with low intake, HED, and 4 (women), 5 (men), or more drinks before injury. At the same level of preattendance drinking, high-volume drinkers were at lower risk than low-volume drinkers. In women, the group of low-risk non-HED drinkers taking fewer than 4 drinks suffered 47.5% of the alcohol-attributable injuries in contrast to only 20.4% for men. Low-volume male drinkers with HED had more alcohol-attributable injuries than that of low-volume female drinkers with HED (46.9% vs 23.2%). CONCLUSIONS: Although all groups of drinkers are at increased risk of alcohol-related injury, those who usually drink little but on occasion heavily are at particular risk. The lower risk of chronic heavy drinkers may be due to higher tolerance of alcohol. Prevention should thus target heavy-drinking occasions. Low-volume drinking women without HED and with only little preattendance drinking experienced a high proportion of injuries; such women would be well advised to drink very little or to take other special precautions in risky circumstances.

The diabetic child in the emergency room

The WHO announced diabetes mellitus as one of the main threats to human health in the 21st century. In children and adolescents the prevalence of both the autoimmune type 1 and the obesity-related type 2 diabetes is increasing. Common to all types of diabetes is an absolute or relative lack of insulin to keep glucose homeostasis under control. Thus children and adolescents with newly diagnosed diabetes present with hyperglycemia which is often accompanied by ketoacidosis bearing the risk of cerebral edema. Children and adolescents with known diabetes treated with insulin or orale antidiabetic agents may also suffer from hyperglycemia or even ketoacidosis during times of non-compliance with diet and drugs or during concomitant illnesses. Hyperglycemia with ketoacidosis is an emergency situation for which patients need to be admitted to the next hospital for administration of insulin, fluids and potassium. In contrast, insulin treatment in diabetic patients may also lead to a hypoglycemia, the sudden drop in blood glucose, at any moment. Thus recognition and correction of mild hypoglycemia should be familiar to every diabetic child and their caretaker. Severe hypoglycemia with or without seizures may bring the diabetic child in a sudden emergency situation for which the administration of glucagon intramuscularly or glucose intravenously is mandatory. After every severe hypoglycemia the insulin and diet regimen of the diabetic child or adolescent must be reviewed with the diabetes specialist. For unexplained hypoglycemia or major treatment adjustments the diabetic child or adolescent may need to be readmitted to the diabetic ward of a hospital to avoid repeat, potentially life-threatening hypoglycemia.

Optimizing Triage and Hospitalization in Adult General Medical Emergency Patients. The Triage Project

Background: Patients presenting to the emergency department (ED) currently face inacceptable delays in initial treatment, and long, costly hospital stays due to suboptimal initial triage and site-of-care decisions. Accurate ED triage should focus not only on initial treatment priority, but also on prediction of medical risk and nursing needs to improve site-of-care decisions and to simplify early discharge management. Different triage scores have been proposed, such as the Manchester triage system (MTS). Yet, these scores focus only on treatment priority, have suboptimal performance and lack validation in the Swiss health care system. Because the MTS will be introduced into clinical routine at the Kantonsspital Aarau, we propose a large prospective cohort study to optimize initial patient triage. Specifically, the aim of this trial is to derive a three-part triage algorithm to better predict (a) treatment priority; (b) medical risk and thus need for in-hospital treatment; (c) post-acute care needs of patients at the most proximal time point of ED admission. Methods/design: Prospective, observational, multicenter, multi-national cohort study. We will include all consecutive medical patients seeking ED care into this observational registry. There will be no exclusions except for non-adult and non-medical patients. Vital signs will be recorded and left over blood samples will be stored for later batch analysis of blood markers. Upon ED admission, the post-acute care discharge score (PACD) will be recorded. Attending ED physicians will adjudicate triage priority based on all available results at the time of ED discharge to the medical ward. Patients will be reassessed daily during the hospital course for medical stability and readiness for discharge from the nurses and if involved social workers perspective. To assess outcomes, data from electronic medical records will be used and all patients will be contacted 30 days after hospital admission to assess vital and functional status, re-hospitalization, satisfaction with care and quality of life measures. We aim to include between 5000 and 7000 patients over one year of recruitment to derive the three-part triage algorithm. The respective main endpoints were defined as (a) initial triage priority (high vs. low priority) adjudicated by the attending ED physician at ED discharge, (b) adverse 30 day outcome (death or intensive care unit admission) within 30 days following ED admission to assess patients risk and thus need for in-hospital treatment and (c) post acute care needs after hospital discharge, defined as transfer of patients to a post-acute care institution, for early recognition and planning of post-acute care needs. Other outcomes are time to first physician contact, time to initiation of adequate medical therapy, time to social worker involvement, length of hospital stay, reasons fordischarge delays, patient’s satisfaction with care, overall hospital costs and patients care needs after returning home. Discussion: Using a reliable initial triage system for estimating initial treatment priority, need for in-hospital treatment and post-acute care needs is an innovative and persuasive approach for a more targeted and efficient management of medical patients in the ED. The proposed interdisciplinary , multi-national project has unprecedented potential to improve initial triage decisions and optimize resource allocation to the sickest patients from admission to discharge. The algorithms derived in this study will be compared in a later randomized controlled trial against a usual care control group in terms of resource use, length of hospital stay, overall costs and patient’s outcomes in terms of mortality, re-hospitalization, quality of life and satisfaction with care.

Hypoglycemic treatment of diabetic patients in the Emergency Department

Objectives: To analyze if the hypoglycemic therapy prescribed in the Emergency Department adapts to the consensus recommendations available, as well as to assess its clinical impact. Methods: A descriptive observational study, which included patients awaiting hospital admission, who were in the Observation Ward of the Emergency Department and had been previously diagnosed with diabetes mellitus, and were receiving treatment with hypoglycemic drugs at home. The management of antidiabetic treatment and its clinical impact were assessed. Results: 78 patients were included. At admission to the Emergency Department, treatment was modified for 91% of patients, and omitted for 9%. The most prescribed treatment was sliding scale insulin (68%). The treatments prescribed coincided in a 16.7% with the recommendations by the Spanish Society of Emergency Medicine. After intervention by the Pharmacist, the omission descended to 1.3%, and the adaptation to the recommendations increased to 20.5%. Comparing patients whose treatment coincided with the recommendations and those who did not, the clinical impact was respectively: mean glycemia at 24 hours: 138.3 ± 49.5 mg/dL versus 182.7 ± 97.1 mg/dL (p = 0.688); mean rescues with insulin lispro: ± 1.6 versus 1.5 ± 1.8 (p = 0.293); mean units of insulin lispro administered: 4.6 ± 12.7 IU versus 6.6 ± 11.3 IU (p = 0.155). Conclusions: We found antidiabetic prescriptions to have a low adaptation to consensus recommendations. These results are in line with other studies, showing an abuse of sliding scale regimen as single hypoglycemic treatment.

Spatial analysis of urban violence based on emergency room data

OBJECTIVE: To estimate the spatial intensity of urban violence events using wavelet-based methods and emergency room data. METHODS: Information on victims attended at the emergency room of a public hospital in the city of São Paulo, Southeastern Brazil, from January 1, 2002 to January 11, 2003 were obtained from hospital records. The spatial distribution of 3,540 events was recorded and a uniform random procedure was used to allocate records with incomplete addresses. Point processes and wavelet analysis technique were used to estimate the spatial intensity, defined as the expected number of events by unit area. RESULTS: Of all georeferenced points, 59% were accidents and 40% were assaults. There is a non-homogeneous spatial distribution of the events with high concentration in two districts and three large avenues in the southern area of the city of São Paulo. CONCLUSIONS: Hospital records combined with methodological tools to estimate intensity of events are useful to study urban violence. The wavelet analysis is useful in the computation of the expected number of events and their respective confidence bands for any sub-region and, consequently, in the specification of risk estimates that could be used in decision-making processes for public policies.

Características dos nascidos vivos, das mães e mortalidade neonatal precoce na Região Metropolitana de São Paulo, Brasil

O objetivo foi descrever as características do recém-nascido, da mãe e da mortalidade neonatal precoce, segundo local de parto, na Região Metropolitana de São Paulo, Brasil. Utilizou-se coorte de nascidos vivos vinculados aos respectivos óbitos neonatais precoces, por técnica determinística. Identificou-se o parto domiciliar a partir da Declaração de Nascido Vivo e os ocorridos em estabelecimentos a partir da vinculação com o Cadastro Nacional de Estabelecimentos de Saúde. Foram estudados 154.676 nascidos vivos, dos quais 0,3% dos nascimentos ocorreram acidentalmente em domicílio, 98,7% em hospitais e menos de 1% em outro serviço de saúde. A mortalidade foi menor no Centro de Parto Normal e nas Unidades Mistas de Saúde, condizente com o perfil de baixo risco obstétrico. As taxas mais elevadas ocorreram nos prontos-socorros (54,4 óbitos por mil nascidos vivos) e domicílios (26,7), representando um risco de morte, respectivamente, 9,6 e 4,7 vezes maior que nos hospitais (5,6). Apesar da alta predominância do parto hospitalar, há um segmento de partos acidentais tanto em domicílios como em prontos-socorros que merece atenção, por registrar elevadas taxas de mortalidade neonatal precoce.

Self-medication: initial treatments used by patients seen in an ophthalmologic emergency room

OBJECTIVE: This study seeks to identify practices of self-medication in the treatment of ocular emergencies. We examine patients' use of both homemade preparations and manufactured products before seeking specialized care. MATERIALS AND METHODS: We conducted a cross-sectional analytic survey of consecutive patients seen in the ophthalmology emergency room of a teaching hospital. RESULTS: The sample included 561 subjects, 51.3% males and 48.7% females, with a mean age of 39.8 years. Prior to seeking emergency care, 40.5% reported self-medicating; 29.4% used a homemade preparation (13.9% referred to an industrialized product like boric acid as a homemade preparation), and 11.1% used a manufactured product. The most frequently used products included a boric acid solution (53.3%), a normal saline solution (35.7%), herbal infusions (6.1%) and breast milk (4.8%). Viral conjunctivitis was the most frequent diagnosis (24.4%), followed by the presence of a corneal foreign body (7.4%). No significant differences were found in the self-treatment of ocular injuries according to gender (p = 0.95), level of education (p = 0.21) or age (p = 0.14). In addition, self-medication practices were not related to the medically judged severity of the condition. CONCLUSION: Patients often attempt to treat conditions that require ophthalmologic emergency care by self-medicating with homemade or manufactured products. The most widely used products include boric acid, normal saline, leaf infusions and breast milk. This behavior occurs independently of educational level, gender, age or the nature of the ocular condition. Self-medication is a culturally driven practice that is used even in cases of acute ocular injuries.

Urban air pollution and chronic obstructive pulmonary disease-related emergency department visits

Background: Patients with chronic obstructive pulmonary disease (COPD) can have recurrent disease exacerbations triggered by several factors, including air pollution. Visits to the emergency respiratory department can be a direct result of short-term exposure to air pollution. The aim of this study was to investigate the relationship between the daily number of COPD emergency department visits and the daily environmental air concentrations of PM(10), SO(2), NO(2), CO and O(3) in the City of Sao Paulo, Brazil. Methods: The sample data were collected between 2001 and 2003 and are categorised by gender and age. Generalised linear Poisson regression models were adopted to control for both short-and long-term seasonal changes as well as for temperature and relative humidity. The non-linear dependencies were controlled using a natural cubic spline function. Third-degree polynomial distributed lag models were adopted to estimate both lag structures and the cumulative effects of air pollutants. Results: PM(10) and SO(2) readings showed both acute and lagged effects on COPD emergency department visits. Interquartile range increases in their concentration (28.3 mg/m(3) and 7.8 mg/m(3), respectively) were associated with a cumulative 6-day increase of 19% and 16% in COPD admissions, respectively. An effect on women was observed at lag 0, and among the elderly the lag period was noted to be longer. Increases in CO concentration showed impacts in the female and elderly groups. NO(2) and O(3) presented mild effects on the elderly and in women, respectively. Conclusion: These results indicate that air pollution affects health in a gender-and age-specific manner and should be considered a relevant risk factor that exacerbates COPD in urban environments.