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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Author: Ivana Kamber

Heart rate variability analysis in acute poisoning by cholinesterase inhibitors


Heart rate variability (HRV) has been associated with a variety of clinical situations. However, few studies have examined the association between HRV and acute poisoning. Organophosphate (OP) and carbamate inhibit esterase enzymes, particularly acetylcholinesterase, resulting in an accumulation of acetylcholine and thereby promoting excessive activation of corresponding receptors. Because diagnosis and treatment of OP and carbamate poisoning greatly depend on the severity of cholinergic symptoms, and because HRV reflects autonomic status, some HRV parameters may be of value in diagnosing OP and carbamate poisoning among patients visiting the emergency department.

Patients who visited the emergency department of the study hospital between September 2008 and May 2010 with the chief complaint of acute poisoning or overdose were included. Cases that involved ingestion of OP or carbamate insecticides were classified as poisoning by cholinesterase inhibitors and compared with other cases of poisoning or overdose. The time-domain analysis included descriptive statistics of R-R intervals and instantaneous heart rates. The frequency-domain analysis used fast Fourier transformation. A Poincaré plot, which is a scatterplot of R-R intervals against the preceding R-R interval, was used for the nonlinear analysis.

Very-low-frequency (VLF) power and the ratio of low-frequency-to-high-frequency power (LF/HF) were the most effective parameters for distinguishing cholinesterase inhibitor poisoning among cases of acute poisoning, with areas under the receiver-operating characteristic curve of 0.76 and 0.87, respectively. Cholinesterase inhibitor poisoning was a significant factor determining VLF power and the LF/HF ratio after adjusting for possible confounding variables, including age over 40, gender, and tracheal intubation.

Frequency-domain parameters of HRV, such as VLF power and the LF/HF ratio, might be considered as potential diagnostic methods to distinguish cholinesterase inhibitor poisoning from other cases of intoxication in the early stages of emergency care.

Key words: electrocardiography, organophosphates, carbamates, poisoning

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Influence of the adequacy of data collection, during two years, in the management of community-acquired pneumonia in emergency departments


Objective. The aim of this study was to analyze whether structured data collection of patients with community-acquired pneumonia (CAP) in the Emergency Department (ED) improves compliance with clinical guidelines regarding inpatient and outpatient treatment and prescription of antibiotics at discharge.
Material and methods. We performed a quasi experimental, multicenter, pre/post-intervention study. The intervention consisted of basic training for the participating physicians and the incorporation of a data collection sheet in the clinical history chart, including the information necessary for adequate decision making regarding patient admission and treatment, in the case of discharge. We analyzed the adequacy of the final destination of patients classified as Fine I-II and antibiotic treatment in patients receiving outpatient treatment, with each participating physician including 8 consecutive patients (4 pre-intervention and 4 post-intervention).
Results. A total of 738 patients were included: 378 pre-intervention and 360 post-intervention. In the pre-intervention group, Fine V was more frequent and patients were older, had more ischemic heart disease, active neoplasms and fewer risk factors for atypical pneumonia. Of the patients with Fine I-II, 23.7% were inadequately admitted and 19.6% of those discharged received treatment not recommended by guidelines. No differences were observed in the target variables between the two groups.
Conclusion. The adequacy of the decision to admit patients with Fine I-II CAP and outpatient antibiotic treatment can be improved in the ED. Structured data collection does not improve patient outcome.

Key words: community-acquired pneumonia, emergency department, antibiotic treatment, adequacy of admission

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Juvenile pelvic extragenital endometrioma with acute abdomen in a 15-year-old girl


We describe a case of a 15-year-old girl with a several month history of chronic pelvic pain, due to a 5 cm pelvic tumour, presenting with acute abdomen. Urgent diagnostic laparoscopy revealed multiple pelvic adhesions and a focal extragenital pelvic tumour. After laparoscopy, ultrasound and magnetic resonance imaging and laboratory procedures (with normal value of oncomarkers) were performed, followed by explorative laparotomy and total tumorectomy. An extragenital pelvic endometrioma was verified on histopathological analysis.

Key words: acute abdomen, pelvic pain, juvenile, endometriosis, extragenital, puberty

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Optic neuritis caused by aspergilloma within Onodi cell pyomucocele in a 62-year-old woman


Onodi cells are anatomical variants of the posterior ethmoidal cells, which are greatly pneumatized laterally, and to some degree superiorly, to the sphenoid sinuses. The clinical importance of the Onodi cell is that it contains the optic canal and lies in close proximity to the optic nerve. Although the incidence of Onodi cell pathologies such as mucocele is extremely low, they may cause ophthalmological complications due to the close anatomical proximity between the Onodi cell and the optic nerve. Optic neuritis caused by aspergillosis of the Onodi cell, presenting in the Emergency Department as an aspergilloma within a pyomucocele, has not been reported previously. Here, we describe the first such case; the aspergilloma within the pyomucocele was completely removed via surgical endoscopy.

Key words: optic neuritis, onodi cell pyomucocele, aspergilloma, CT, MRI

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