Spectrum of digoxin-induced ocular toxicity: a case report and literature review.

BACKGROUND: Digoxin intoxication results in predominantly digestive, cardiac and neurological symptoms. This case is outstanding in that the intoxication occurred in a nonagenarian and induced severe, extensively documented visual symptoms as well as dysphagia and proprioceptive illusions. Moreover, it went undiagnosed for a whole month despite close medical follow-up, illustrating the difficulty in recognizing drug-induced effects in a polymorbid patient. CASE PRESENTATION: Digoxin 0.25 mg qd for atrial fibrillation was prescribed to a 91-year-old woman with an estimated creatinine clearance of 18 ml/min. Over the following 2-3 weeks she developed nausea, vomiting and dysphagia, snowy and blurry vision, photopsia, dyschromatopsia, aggravated pre-existing formed visual hallucinations and proprioceptive illusions. She saw her family doctor twice and visited the eye clinic once until, 1 month after starting digoxin, she was admitted to the emergency room. Intoxication was confirmed by a serum digoxin level of 5.7 ng/ml (reference range 0.8-2 ng/ml). After stopping digoxin, general symptoms resolved in a few days, but visual complaints persisted. Examination by the ophthalmologist revealed decreased visual acuity in both eyes, 4/10 in the right eye (OD) and 5/10 in the left eye (OS), decreased color vision as demonstrated by a score of 1/13 in both eyes (OU) on Ishihara pseudoisochromatic plates, OS cataract, and dry age-related macular degeneration (ARMD). Computerized static perimetry showed non-specific diffuse alterations suggestive of either bilateral retinopathy or optic neuropathy. Full-field electroretinography (ERG) disclosed moderate diffuse rod and cone dysfunction and multifocal ERG revealed central loss of function OU. Visual symptoms progressively improved over the next 2 months, but multifocal ERG did not. The patient was finally discharged home after a 5 week hospital stay. CONCLUSION: This case is a reminder of a complication of digoxin treatment to be considered by any treating physician. If digoxin is prescribed in a vulnerable patient, close monitoring is mandatory. In general, when facing a new health problem in a polymorbid patient, it is crucial to elicit a complete history, with all recent drug changes and detailed complaints, and to include a drug adverse reaction in the differential diagnosis.

Teho-osaston ja valvontaosaston rakentamisen kannattavuus Oulun yliopistollisessa sairaalassa

Diplomityön tavoitteena oli määrittää Oulun yliopistollisen sairaalan Leikkaus- ja tehohoidon tulosyksikön teho- ja valvontaosaston paikkatarve sekä selvittää, miten sijainti vaikuttaa toimintaan, kun teho-osasto muuttaa kirurgian poliklinikan tiloihin ja sijainti muuttuu yhteispäivystysyksikköön, leikkausosastoon ja vuodeosastoihin nähden. Lisäksi selvitettiin, mihin uusi valvontaosasto kannattaa rakentaa sekä ra kentamishankkeen kannattavuus käyttämällä kolmea eri laskentamenetelmää. Työn teoria- ja empiriaosuus on osittain yhdistetty, mikä helpottaa työn seuraamista ja parantaa loogisuutta. Teoriaosuudessa käsitellään investointien kannattavuuden arviointia, poistojen vaikutusta talouteen, Pohjois-Pohjanmaan sairaanhoitopiiriä ja Leikkaus- ja tehohoidon tulosyksikön toimintaa sekä erityisesti tehohoitotyötä ja teho-osaston toimintaa. Empiriaosuus koostuu erityisvastuualueen väestönkehityksen arvioinnista, johon tulevaisuuden tehohoitotarve pohjautuu sekä teho- ja valvon taosaston paikkatarpeen määrityksestä ja investoinnin kannattavuuden arvioinnista. Työ antaa hyvän pohjan teho- ja valvontaosaston rakentamissuunnittelulle, ja investointien tarkastelu taloudelliselta näkökulmalta toimii tukena investointipäätöksenteolle. Tämän työn tuloksena teho- ja valvontaosaston rakentaminen on kannattavaa kolmen eri investointilaskelmamenetelmän perusteella.

De novo undifferentiated pleomorphic sarcoma arising from a renal allograft: A case report

To the best of our knowledge, this is the first report of an undifferentiated pleomorphic sarcoma arising from a renal graft. Transplantectomy was performed in a 47-year old woman presenting to the emergency room because of general weakness. Preoperative workup revealed a 5.5 cm malignant mass of the graft which was not present on routine ultrasound performed 12 months earlier. Following transplantectomy, local recurrence developed despite complete tumor resection and interruption of immunosuppression. Despite radiation therapy, the outcome was ultimately fatal. Genetic analysis revealed that the tumor had arisen from donor tissue. Annual ultrasound surveillance might not be enough effective to screen for these rare high grade neoplasms.

Perfuração gástrica por tricobezoar

Bezoars are uncommon foreign bodies found in the stomach and intestines. They are usually secundary to "strange" or "weird" alimentary habits. The contents may include hait; stones, vegetal fibers and others. Diagnosis is generally made due to complications, mainly parcial or complete obstruction of the segment affected. Bleeding and peiforation may also occur: This paper describes a case of a 14-years-old female patient, who presented herself to lhe Emergency Room and was diagnosed as having a gastric peiforation due to a trichobezoar that was 15 cm long and weighted 900g. A review of lhe literature and comments about diagnosis and management are presented.

Comparative analysis between identified injuries of victims of fall from height and other mechanisms of closed trauma

OBJECTIVE: To analyze the lesions diagnosed in victims of falls, comparing them with those diagnosed in other mechanisms of blunt trauma.METHODS: We conducted a retrospective study of trauma protocol charts (prospectively collected) from 2008 to 2010, including victims of trauma over 13 years of age admitted to the emergency room. The severity of injuries was stratified by the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS). Variables were compared between the group of victims of falls from height (Group 1) and the other victims of blunt trauma (Group 2). We used the Student t, chi-square and Fisher tests for comparison between groups, considering the value of p <0.05 as significant.RESULTS: The series comprised 4,532 cases of blunt trauma, of which 555 (12.2%) were victims of falls from height. Severe lesions (AISe"3) were observed in the extremities (17.5%), in the cephalic segment (8.4%), chest (5.5%) and the abdomen (2.9%). Victims of Group 1 had significantly higher mean age, AIS in extremities / pelvis, AIS in the thoracic segment and ISS (p <0.05). The group 1 had significantly (p <0.05) higher incidence of tracheal intubation on admission, pneumothorax, hemothorax, rib fractures, chest drainage, spinal trauma, pelvic fractures, complex pelvic fractures and fractures to the upper limbs.CONCLUSION: Victims of fall from height had greater anatomic injury severity, greater frequency and severity of lesions in the thoracic segment and extremities.

Spontaneous rupture of renal angiomyolipoma during pregnancy

Renal angiomyolipoma is a benign tumor, composed of adipocytes, smooth muscle cells and blood vessels. The association with pregnancy is rare and related with an increased risk of complications, including rupture with massive retroperitoneal hemorrhage. The follow-up is controversial because of the lack of known cases, but the priorities are: timely diagnosis in urgent cases and a conservative treatment when possible. The mode of delivery is not consensual and should be individualized to each case. We report a case of a pregnant woman with 18 weeks of gestation admitted in the emergency room with an acute right low back pain with no other symptoms. The diagnosis of rupture of renal angiomyolipoma was established by ultrasound and, due to hemodinamically stability, conservative treatment with imaging and clinical monitoring was chosen. At 35 weeks of gestation, it was performed elective cesarean section without complications for both mother and fetus.

Intravenous dipyrone for the acute treatment of episodic tension-type headache: A randomized, placebo-controlled, double-blind study

Acute headaches are responsible for a significant percentage of the case load at primary care units and emergency rooms in Brazil. Dipyrone (metamizol) is easily available in these settings, being the most frequently used drug. We conducted a randomized, placebo-controlled, double-blind study to assess the effect of dipyrone in the acute treatment of episodic tension-type headache. Sixty patients were randomized to receive placebo (intravenous injection of 10 ml saline) or 1 g dipyrone in 10 ml saline. We used seven parameters of analgesic evaluation. The patients receiving dipyrone showed a statistically significant improvement (P<0.05) of pain compared to placebo up to 30 min after drug administration. The therapeutic gain was 30% in 30 min and 40% in 60 min. The number of patients needed to be treated for at least one to have benefit was 3.3 in 30 min and 2.2 in 60 min. There were statistically significant reductions in the recurrence (dipyrone = 25%, placebo = 50%) and use of rescue medication (dipyrone = 20%, placebo = 47.6%) for the dipyrone group. Intravenous dipyrone is an effective drug for the relief of pain in tension-type headache and its use is justified in the emergency room setting.

Direct costs of asthma in Brazil: a comparison between controlled and uncontrolled asthmatic patients

Asthma is a common chronic illness that imposes a heavy burden on all aspects of the patient's life, including personal and health care cost expenditures. To analyze the direct cost associated to uncontrolled asthma patients, a cross-sectional study was conducted to determine costs related to patients with uncontrolled and controlled asthma. Uncontrolled patient was defined by daytime symptoms more than twice a week or nocturnal symptoms during two consecutive nights or any limitations of activities, or need for relief rescue medication more than twice a week, and an ACQ score less than 2 points. A questionnaire about direct cost stratification in health services, including emergency room visits, hospitalization, ambulatory visits, and asthma medications prescribed, was applied. Ninety asthma patients were enrolled (45 uncontrolled/45 controlled). Uncontrolled asthmatics accounted for higher health care expenditures than controlled patients, US$125.45 and US$15.58, respectively [emergency room visits (US$39.15 vs US$2.70) and hospitalization (US$86.30 vs US$12.88)], per patient over 6 months. The costs with medications in the last month for patients with mild, moderate and severe asthma were US$1.60, 9.60, and 25.00 in the uncontrolled patients, respectively, and US$6.50, 19.00 and 49.00 in the controlled patients. In view of the small proportion of uncontrolled subjects receiving regular maintenance medication (22.2%) and their lack of resources, providing free medication for uncontrolled patients might be a cost-effective strategy for the public health system.

Effect of air pollution on diabetes and cardiovascular diseases in São Paulo, Brazil

Type 2 diabetes increases the risk of cardiovascular mortality and these patients, even without previous myocardial infarction, run the risk of fatal coronary heart disease similar to non-diabetic patients surviving myocardial infarction. There is evidence showing that particulate matter air pollution is associated with increases in cardiopulmonary morbidity and mortality. The present study was carried out to evaluate the effect of diabetes mellitus on the association of air pollution with cardiovascular emergency room visits in a tertiary referral hospital in the city of São Paulo. Using a time-series approach, and adopting generalized linear Poisson regression models, we assessed the effect of daily variations in PM10, CO, NO2, SO2, and O3 on the daily number of emergency room visits for cardiovascular diseases in diabetic and non-diabetic patients from 2001 to 2003. A semi-parametric smoother (natural spline) was adopted to control long-term trends, linear term seasonal usage and weather variables. In this period, 45,000 cardiovascular emergency room visits were registered. The observed increase in interquartile range within the 2-day moving average of 8.0 µg/m³ SO2 was associated with 7.0% (95%CI: 4.0-11.0) and 20.0% (95%CI: 5.0-44.0) increases in cardiovascular disease emergency room visits by non-diabetic and diabetic groups, respectively. These data indicate that air pollution causes an increase of cardiovascular emergency room visits, and that diabetic patients are extremely susceptible to the adverse effects of air pollution on their health conditions.

Phenotypic and genotypic variant of MDR-Mycobacterium tuberculosis multiple isolates in the same tuberculosis episode, Rio de Janeiro, Brazil

Assuming that the IS6110-restriction fragment length polymorphism (RFLP) changes at a constant rate of 3.2 years, this methodology was applied to demonstrate, for the first time, variant patterns of Mycobacterium tuberculosis (MTB) in multiple isolates obtained at short time intervals from sputum and blood of an HIV+ patient with multiple admissions to the Emergency Room and to the multidrug-resistant tuberculosis (MDR-TB) Reference Center of a secondary-care hospital in Rio de Janeiro, Brazil. In sputum, the IS6110-RFLP appeared in isolates with two variant patterns with 10 and 13 IS6110 copies. However, blood presented only the pattern corresponding to 10 copies, suggesting compartmentalization. With regard to the exact match of 10 of 13 bands, this may be a subpopulation with the same clonal origin and this may be related to the IS6110 transposition. A susceptibility test demonstrated an MDR profile (INH R, RIF R, SM R, and EMB R), with the sputum isolate also exhibiting EMB S (R = resistant; S = sensitive). A gene mutation confirmed resistance only to streptomycin. There was agreement between the results of the phenotypic test and the clinical response to MDR-TB treatment, suggesting serious implications with regard to treatment administration based exclusively on molecular methods, and calling attention to the fact that more effective control strategies against the emergence of MDR strains must be implemented by the TB control program to prevent transmission of MDR-MTB strains at health facilities in areas highly endemic for TB.

Rabbit model of uncontrolled hemorrhagic shock and hypotensive resuscitation

Clinically relevant animal models capable of simulating traumatic hemorrhagic shock are needed. We developed a hemorrhagic shock model with male New Zealand rabbits (2200-2800 g, 60-70 days old) that simulates the pre-hospital and acute care of a penetrating trauma victim in an urban scenario using current resuscitation strategies. A laparotomy was performed to reproduce tissue trauma and an aortic injury was created using a standardized single puncture to the left side of the infrarenal aorta to induce hemorrhagic shock similar to a penetrating mechanism. A 15-min interval was used to simulate the arrival of pre-hospital care. Fluid resuscitation was then applied using two regimens: normotensive resuscitation to achieve baseline mean arterial blood pressure (MAP, 10 animals) and hypotensive resuscitation at 60% of baseline MAP (10 animals). Another 10 animals were sham operated. The total time of the experiment was 85 min, reproducing scene, transport and emergency room times. Intra-abdominal blood loss was significantly greater in animals that underwent normotensive resuscitation compared to hypotensive resuscitation (17.1 ± 2.0 vs 8.0 ± 1.5 mL/kg). Antithrombin levels decreased significantly in normotensive resuscitated animals compared to baseline (102 ± 2.0 vs 59 ± 4.1%), sham (95 ± 2.8 vs 59 ± 4.1%), and hypotensive resuscitated animals (98 ± 7.8 vs 59 ± 4.1%). Evidence of re-bleeding was also noted in the normotensive resuscitation group. A hypotensive resuscitation regimen resulted in decreased blood loss in a clinically relevant small animal model capable of reproducing hemorrhagic shock caused by a penetrating mechanism.

Schizophrénie et dépression : Recours aux services avant et après une hospitalisation pour tentative de suicide

Contexte : Une tentative de suicide antérieure et les troubles mentaux constituent d’importants facteurs de risque de suicide. Les services de santé ont un rôle important à jouer en matière de prévention. Objectif : Analyser les patrons de recours aux services à des fins de santé mentale avant et après une hospitalisation pour tentative de suicide chez les résidents montréalais qui ont reçu un diagnostic de schizophrénie ou de dépression. Méthode : Les données proviennent de la banque médico administrative jumelée de l’Agence de Montréal. Les caractéristiques des patients et les taux de contacts avec les services trois mois avant et après l’hospitalisation index furent comparées. L’échantillon représentatif compte 525 Montréalais hospitalisés à la suite d’une tentative de suicide (avr. 2003-déc. 2004) qui ont reçu un diagnostic de schizophrénie ou de dépression. Résultats : Le recours aux services a augmenté de manière significative suivant l’hospitalisation index. Les patients déjà en contact avec les services et les hommes avec comorbidité en termes d’abus de substances semblent en contact avec les services au cours des trois mois suivant leur hospitalisation contrairement aux femmes avec comorbidité. Le profil « urgence » de recours aux services semble prédire une absence de recours aux services. Conclusions : Les services de santé répondent aux tentatives de suicide, particulièrement chez les hommes avec troubles d’abus de substances. Cependant, des interventions sont requises en vue d’améliorer la coordination des services, principalement pour les personnes qui se présentent l’urgence, les femmes avec troubles d’abus de substances et les patients en marge du système avant leur hospitalisation.

Évaluation des systèmes symboliques des symptômes biomédicaux pour la création d’une interface graphique pluriculturelle de l’échelle de triage canadien

Au croisement de l’anthropologie médicale, de la communication, du design industriel et des nouvelles technologies de l’information, ce mémoire se penche sur les difficultés communicatives rencontrées par le personnel médical et les patients de provenances culturelles variées dans le milieu des urgences hospitalières à Montréal. Dans l’optique d’améliorer l’échange au poste de triage, la réflexion porte principalement sur la pertinence et les caractéristiques d’un support visuel d’appoint. Elle aborde la problématique par l’étude des concepts de perception, de compréhension, d’interprétation et de représentation graphique sous les angles théoriques de la communication visuelle (Benjamin, Berger, Dibi-Huberman), de la sémiologie du discours social (Verón) et du jeu herméneutique (Gadamer). Les systèmes symboliques de cent cinquante images, illustrant sur Internet trois symptômes propres à la gastro-entérite, ont été analysés d’après une méthodologie mixte quantitative et qualitative afin d’identifier leurs sens dénotatifs et connotatifs. Les résultats appuient le recours à des images pour contourner les barrières langagières et révèlent l’existence d’une culture médicale visuelle internationale dont le code iconographique est hybride et pluriculturel. Ces nouvelles informations indiquent des critères de performance et des hypothèses concernant les changements occasionnés par l’ajout d’un support visuel dans la dynamique communicationnelle de l’ETC. La recherche ouvre aussi une piste vers l’étude herméneutique du produit en design industriel.

Un modèle global et intégré de la performance : application à l’urgence d’un hôpital au Mexique

À cause de la nature complexe et non linéaire de leurs opérations, les salles d’urgence (SU) constituent des entités organisationnelles uniques dans le domaine de la santé. Les SU subissent des pressions accrues résultant des dynamiques des sociétés contemporaines et de leurs systèmes de santé, et font face ainsi à des défis uniques comme l’engorgement. Contrairement aux croyances dominantes sur le phénomène, le présent travail de recherche établit que ce problème est en réalité une manifestation de pauvre performance systémique plutôt qu’une faillite opérationnelle. Alors, pour les SU, la performance organisationnelle relève une importance incontestable. En effet, l’étude de la performance organisationnelle est un sujet de recherche qui intéresse de nombreux chercheurs des services de santé. Il s’agit, néanmoins, d’un concept historiquement difficile à définir à cause de son caractère complexe, multidimensionnel et paradoxal. Le modèle EGIPSS, basé sur la théorie de l’action sociale de Parsons, est capable de saisir cette complexité et constitue un cadre conceptuel robuste et exhaustif, pouvant s’adapter à des contextes divers. Ce mémoire adopte le modèle EGIPSS pour présenter un outil global et intégré d’évaluation de la performance organisationnelle de la salle d’urgences de l’Hôpital Général Régional 46 à Guadalajara, au Mexique. Cet instrument est conçu pour prendre en compte spécifiquement les particularités propres des SU, ainsi que les caractéristiques organisationnelles uniques de l'Hôpital Général Régional 46. Enfin, le développement de ce projet de mémoire contribue aux efforts d’amélioration continue de la performance de cet établissement, et enrichit les connaissances sur les urgences en tant qu’unités organisationnelles.

D'étudiante à infirmière d'urgence : une étude qualitative de l'expérience d'infirmières nouvellement diplômées ayant participé à un séminaire de soutien et de formation

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal