National Study of United States Emergency Department Visits for Acute Pancreatitis, 1993–2003

Background: The epidemiology of acute pancreatitis in the United States is largely unknown, particularly episodes that lead to an emergency department (ED) visit. We sought to address this gap and describe ED practice patterns. Methods: Data were collected from the National Hospital Ambulatory Medical Care Survey between 1993 and 2003. We examined demographic factors and ED management including medication administration, diagnostic imaging, and disposition. Results: ED visits for acute pancreatitis increased over the study period from the 1994 low of 128,000 visits to a 2003 peak of 318,000 visits (p = 0.01). The corresponding ED visit rate per 10,000 U.S. population also increased from 4.9 visits (95%CI, 3.1–6.7) to 10.9 (95%CI, 7.6–14.3) (p = 0.01). The average age for patients making ED visits for acute pancreatitis during the study period was 49.7 years, 54% were male, and 27% were black. The ED visit rate was higher among blacks (14.7; 95%CI, 11.9–17.5) than whites (5.8; 95%CI, 5.0–6.6). At 42% of ED visits, patients did not receive analgesics. At 10% of ED visits patients underwent CT or MRI imaging, and at 13% of visits they underwent ultrasound testing. Two-thirds of ED visits resulted in hospitalization. Risk factors for hospitalization were older age (multivariate odds ratio for each increasing decade 1.5; 95%CI, 1.3–1.8) and white race (multivariate odds ratio 2.3; 95%CI, 1.2–4.6). Conclusion: ED visits for acute pancreatitis are rising in the U.S., and ED visit rates are higher among blacks than whites. At many visits analgesics are not administered, and diagnostic imaging is rare. There was greater likelihood of admission among whites than blacks. The observed race disparities in ED visit and admission rates merit further study

Idiomas, Viajes y Experiencias Académicas: el Inesperado Choque Cultural en Estudiantes Universitarios

We live in an era in which traveling has become a necessity, either because we are looking for better job opportunities, for study purposes, change our residence or simply to take advantage of our free time. Whatever the reason, culture shock occurs, which can have a negative or positive impact on a person's emotional stability, as they face situations that alter their daily lives, such as diversity of ways of being, thinking, and doing; different languages and customs, climate variability, and geographic spaces. This paper reflects on the symbolic confrontation represented by the change of cultural environment, based on the experiences of those who have lived it; for this purpose, semi-structured interviews were conducted with university students who changed their residence for academic reasons; it is part of qualitative research aimed at analyzing the impact of culture shock on academic achievement. The results indicate that the participants experienced this before starting, which implies an invisible barrier in the process of adapting to the new environment. It is concluded that it is necessary to be aware of the changes involved in leaving the daily space, so students who carry out academic stays should explore the sociocultural aspects of the place where they will arrive, as well as prepare themselves psychologically.Vivimos en una época en la que viajar se ha convertido en una necesidad, ya sea porque se buscan mejores oportunidades laborales, por cuestiones de estudios, por cambiar de residencia o simplemente por aprovechar el tiempo libre. Sea cual sea el motivo, se presenta el choque cultural, que puede impactar de forma negativa o positiva en la estabilidad emocional de una persona, ya que se enfrentan a situaciones que alteran su cotidianidad, como diversidad de formas de ser, pensar y hacer; distintos idiomas y costumbres, variabilidad climática y espacios geográficos. En este documento se reflexiona acerca del enfrentamiento simbólico que representa el cambio de entorno cultural, a partir de experiencias de quienes lo han vivido; para ello se realizaron entrevistas semiestructuradas a estudiantes universitarios que por razones académicas cambiaron de residencia; forma parte de una investigación cualitativa que tiene el objetivo de analizar el impacto del choque cultural en el aprovechamiento académico. Los resultados indican que los participantes lo experimentaron antes de empezar, lo que implica una barrera invisible en el proceso de adaptación del nuevo entorno; se concluye que es necesario la sensibilización respecto a los cambios que implican salir del espacio cotidiano, por lo que el alumnado que realiza estancias académicas deberá explorar los aspectos socioculturales del lugar al que llegará, así como prepararse psicológicamente.&nbsp

Análisis de satisfacción de los clientes de los autoservicios "Abastos la Popa" de la sociedad J. J. Comercializadora la Popa LTDA

Se realizó un documento que contiene información acerca del análisis de satisfacción e insatisfacción expresada por los clientes actuales de Abastos la Popa y además se realizaron sugerencias basados en estos para que los directivos de Abastos la Popa adopten los correctivos necesarios para con esto lograr un mayor nivel de satisfacción de sus clientes. Antes de conocer los resultados del nivel de satisfacción de los clientes y expresar las sugerencias necesarias se debe conocer primero en que consiste el nivel de satisfacción e insatisfacción de los clientes y el comportamiento post-compra. “La satisfacción del comprador esta en el centro de la gestión del marketing, y, sin embargo, solamente desde hace poco las empresas se esfuerzan en medir sistemáticamente el grado de satisfacción de sus usuarios. Anteriormente los análisis se limitaban a medidas internas de la calidad del tipo ISO-9000. La medida de satisfacción mas evidente parecía ser el nivel de ventas o de la cuota de mercado, del mismo modo que el nivel (eventual) de insatisfacción parecía quedar reflejado en el número de quejas”1 Asimismo, se debe tener en cuenta que puede existir una diferencia muy importante entre lo que la empresa piensa que desea el comprador y lo que realmente quiere el cliente, o dicho de otro modo entre la calidad que concibe el fabricante y la calidad buscada o percibida por el comprador, sin que este exprese necesariamente su insatisfacción. De hay la necesidad de preguntarle directamente al comprador y de medir formalmente su grado de satisfacción/ insatisfacción

Serum 25-Hydroxyvitamin D Levels Among Boston Trainee Doctors in Winter

As indoor workers, trainee doctors may be at risk for inadequate vitamin D. All trainee doctors (residents) in a Boston pediatric training program (residency) were invited to complete a survey, and undergo testing for serum 25-hydroxyvitamin D [25(OH)D], PTH, and calcium during a 3-week period in March 2010. We examined the association between resident characteristics and serum 25(OH)D using Chi2 and Kruskal-Wallis test and multivariable linear and logistic regression. Of the 119 residents, 102 (86%) participated. Although the mean serum 25(OH)D level was 67 nmol/L (±26), 25 (25%) had a level <50 nmol/L and 3 (3%) residents had levels <25 nmol/L. In the multivariable model, factors associated with 25(OH)D levels were: female sex (β 12.7, 95% CI 3.6, 21.7), white race (β 21.7, 95% CI 11.7, 31.7), travel to more equatorial latitudes during the past 3 months (β 6.3, 95% CI 2.0, 10.5) and higher daily intake of vitamin D (β 1.1, 95% CI 0.04, 2.1). Although one in four residents in our study had a serum 25(OH)D <50 nmol/L, all of them would have been missed using current Centers for Medicare and Medicaid Services (CMS) screening guidelines. The use of traditional risk factors appears insufficient to identify low vitamin D in indoor workers at northern latitudes

Established and Novel Initiatives to Reduce Crowding in Emergency Departments

Introduction: The American College of Emergency Physicians (ACEP) Task Force on Boarding described high-impact initiatives to decrease crowding. Furthermore, some emergency departments (EDs) have implemented a novel initiative we term “vertical patient flow,” i.e. segmenting patients who can be safely evaluated, managed, admitted or discharged without occupying a traditional ED room. We sought to determine the degree that ACEP-identified high-impact initiatives for ED crowding and vertical patient flow have been implemented in academic EDs in the United States (U.S.). Methods: We surveyed the physician leadership of all U.S. academic EDs from March to May 2010 using a 2-minute online survey. Academic ED was defined by the primary site of an emergency residency program. Results: We had a response rate of 73% (106/145) and a completion rate of 71% (103/145). The most prevalent hospital-based initiative was inpatient discharge coordination (46% [47/103] of respondents) while the least fully initiated was surgical schedule smoothing (11% [11/103]). The most prevalent ED-based initiative was fast track (79% [81/103]) while the least initiated was physician triage (12% [12/103]). Vertical patient flow had been implemented in 29% (30/103) of responding EDs while an additional 41% (42/103) reported partial/in progress implementation. Conclusion: We found great variability in the extent academic EDs have implemented ACEP’s established high-impact ED crowding initiatives, yet most (70%) have adopted to some extent the novel initiative vertical patient flow. Future studies should examine barriers to implementing these crowding initiatives and how they affect outcomes such as patient safety, ED throughput and patient/provider satisfaction

Confirmatory Spirometry for Adults Hospitalized with a Diagnosis of Asthma or Chronic Obstructive Pulmonary Disease Exacerbation

Background: Objective measurement of airflow obstruction by spirometry is an essential part of the diagnosis of asthma or COPD. During exacerbations, the feasibility and utility of spirometry to confirm the diagnosis of asthma or chronic obstructive pulmonary disease (COPD) are unclear. Addressing these gaps in knowledge may help define the need for confirmatory testing in clinical care and quality improvement efforts. This study was designed to determine the feasibility of spirometry and to determine its utility to confirm the diagnosis in patients hospitalized with a physician diagnosis of asthma or COPD exacerbation. Methods: Multi-center study of four academic healthcare institutions. Spirometry was performed in 113 adults admitted to general medicine wards with a physician diagnosis of asthma or COPD exacerbation. Two board-certified pulmonologists evaluated the spirometry tracings to determine the proportion of patients able to produce adequate quality spirometry data. Findings were interpreted to evaluate the utility of spirometry to confirm the presence of obstructive lung disease, according to the 2005 European Respiratory Society/American Thoracic Society recommendations. Results: There was an almost perfect agreement for acceptability (κ = 0.92) and reproducibility (κ =0.93) of spirometry tracings. Three-quarters (73%) of the tests were interpreted by both pulmonologists as being of adequate quality. Of these adequate quality tests, 22% did not present objective evidence of obstructive lung disease. Obese patients (BMI ≥30 kg/m2) were more likely to produce spirometry tracings with no evidence of obstructive lung disease, compared to non-obese patients (33% vs. 8%, p = 0.007). Conclusions: Adequate quality spirometry can be obtained in most hospitalized adults with a physician diagnosis of asthma or COPD exacerbation. Confirmatory spirometry could be a useful tool to help reduce overdiagnosis of obstructive lung disease, especially among obese patients

Evaluación de algoritmos basados en lógica difusa para el procesamiento de señales de registro de pozo abierto.

Today it is very common to use intelligent computational techniques to solve&nbsp; problems of characterization, pattern recognition and decision making. Log interpretation is used to discover rock and fluid properties in order to find possible hydrocarbon zones in underground geological formations, using information and knowledge systems lith Database, an expert systems, in out where fuzzy logic offers many tools to achieve its goals. This document focuses on the implementation and evaluation of algorithms based on fuzzy logic&nbsp; applied to information and knowledge systems of well profiling to conduct the characterization and identification zones of interest (hydrocarbon zones) and processing open hole log data. The final product is a&nbsp; file&nbsp; developed in a Matlab® environment. The profile values of gamma ray, porosity, resistivity and spontaneous potential mustbe loaded and the program&nbsp;&nbsp; obtains the zones of interest of each open hole, base d on the values of the named parameters.Hoy en día es muy común el uso de técnicas computacionales inteligentes para la solución de problemas de caracterización, reconocimiento de patrones y toma de decisiones. Con la interpretación de perfiles se busca conocer las propiedades de la roca y fluidos para encontrar posibles zonas de hidrocarburos en las formaciones geológicas del subsuelo, mediante el uso de sistemas de información y conocimiento como bases de datos, sistemas expertos, dentro de los cuales la lógica difusa presenta un conjunto de herramientas que facilitan el alcance de sus objetivos.&nbsp; En este documento se presenta la implementación y evaluación de algoritmos basados en lógica difusa aplicados al sistema de información y conocimiento de perfiles de pozos, para llevar a cabo la caracterización e identificación de zonas de interés (zonas que contienen hidrocarburos), procesando datos de perfiles de pozo abierto. El producto final es un archivo desarrollado en el entorno de Matlab®, donde se cargan los datos de perfiles de Rayos Gamma, Porosidad, Resistividad y Potencial espontáneo, y con base en el valor de los anteriores parámetros, se obtienen las zonas de interés de cada pozo

The long-term prognostic value of serum 25(OH)D, albumin, and LL-37 levels in acute respiratory diseases among older adults

Background Older adults are more susceptible to respiratory tract infection than healthy working age adults. The increased susceptibility of older adults is thought to be interlinked with vitamin D status, nourishment, and immunological state in general. Data are scarce whether these parameters could serve as prognostic markers. Aim To study whether serum 25(OH)D, albumin, and LL-37 level could give prognostic value of long-term survival in the older adults with multimorbidity and acute respiratory infection. Methods Consecutive episodes of hospital care of patients 65 years and older with respiratory symptoms were prospectively studied as a cohort. Standard clinical questionnaire was filled by the study physician. Laboratory markers included serum levels of 25(OH)D, albumin and LL-37, C-reactive protein (CRP), white blood cell count (WBC) and polymerase chain reaction diagnostics for 14 respiratory viruses. Pneumonia was confirmed by chest radiographs. Respiratory illness severity, death at ward, length of hospital stays, and 5-year survival were used as outcomes. Results In total, 289 older adult patients with mean age of 83 years were included in the study. Serum 25(OH)D deficiency (< 50 nmol/liter) was present in 59% and hypoalbuminemia (< 3.5 g/dL) in 55% of the study patients. Low serum albumin level was associated to one, two- and five-year mortality after hospital stay (all P < .05). In addition, it was associated with pneumonia, dyspnea, over 13-night long stay at ward and death at ward (all P < .05). No associations were seen between serum 25(OH)D and LL-37 levels and disease severity, short-term clinical outcome, or long-term survival. Associations between serum 25(OH)D, albumin, and LL-37 levels and respiratory virus presence were not seen. Conclusions Serum albumin level on admission seems to give valuable information about the patients' general health and recovery potential in treating older adults with respiratory symptoms. Serum 25(OH)D and LL-37 had no associations with disease severity or long- and short-term prognosis among older adults hospitalized with respiratory symptoms.Peer reviewe

Plasmodium malariae in the Colombian Amazon region : You don't diagnose what you don't suspect

Background: Malaria is a worldwide public health problem; parasites from the genus Plasmodium spp. are the aetiological agent of this disease. The parasite is mainly diagnosed by microscope-based techniques. However, these have limited sensitivity. Many asymptomatic infections are sub-microscopic and can only be detected by molecular methods. This study was aimed at comparing nested PCR results to those obtained by microscope for diagnosing malaria and to present epidemiological data regarding malaria in Colombia's Amazon department. Methods: A total of 1392 blood samples (taken by venepuncture) from symptomatic patients in Colombia's Amazon department were analysed in parallel by thick blood smear (TBS) test and nested PCR for determining Plasmodium spp. infection and identifying infecting species, such as Plasmodium vivax, Plasmodium malariae and/or Plasmodium falciparum. Descriptive statistics were used for comparing the results from both tests regarding detection of the disease, typing infecting species and their prevalence in the study region. Bearing the microscope assay in mind as gold standard, PCR diagnosis performance was evaluated by statistical indicators. Conclusion: The present study revealed great differences between both diagnostic tests, as well as suggesting high P. malariae prevalence from a molecular perspective. This differed profoundly from previous studies in this region of Colombia, usually based on the TBS test, suggesting that diagnosis by conventional techniques could lead to underestimating the prevalence of certain Plasmodium spp. having high circulation in this area. The present results highlight the need for modifying state malaria surveillance schemes for more efficient strategies regarding the detection of this disease in endemic areas. The importance of PCR as a back-up test in cases of low parasitaemia or mixed infection is also highlighted. © 2016 The Author(s)

The role of the central serotonergic system in the etiopathogenesis of neurocardiogenic syncope

La implementación de la prueba de mesa basculante en el año 1986 para el diagnóstico de pacientes con síncope recurrente de origen no aclarado, determinó al síncope neurocardiogénico como una de las causas más prevalentes de disfunción autonómica cardiovascular. A pesar de su importancia en términos de salud pública, la fi siopa-tología del síncope neurocardiogénico no ha sido completamente aclarada, difi cultando así la implementación de un enfoque terapéu-tico apropiado. El refl ejo de Bezold-Jarisch propuesto inicialmente como mecanismo causante del síncope neurocardiogénico ha sido recientemente desvirtuado y actualmente se ha sugerido que la etiología del síncope neurocardiogénico puede estar relacionada con alteraciones hormonales y en la neurotransmisón derivadas del sistema nervioso central. Múltiples mecanismos han sido postulados involucrando alteraciones en vías nerviosas centrales y periféricas que llevan a hipotensión y bradicardia súbitas relacionadas con una inhibición del infl ujo simpático. Recientemente se ha postulado que la alteración del sistema central serotoninérgico podría ser un elemento clave en la fisiopatología del síncope neurocardiogénico. En este papel se revisan algunos aspectos del rol del sistema central serotoninérgico en la regulación de la función cardiovascular, presentando datos que sugieren su potencial participación en el síncope neurocardiogénico. [García R, Guzmán JC, Silva SY, Zarruk JG, López-Jaramillo P, Morillo CA, Silva FA. El papel del sistema serotoninérgico central en la etiopatogenia del síncope neurocar-diogénico.The implementation of the tilt test in 1986 as a diagnostic tool for unexplained syncope, established to the neurocardiogenic syncope as the most common cause of recurrent fainting in the general popu-lation. Despite its prevalence, the pathophysiology and treatment of the neurocardiogenic syncope remains to be elucidated. It was formerly believed that the Bezold-Jarisch refl ex was the trigger-ing factor for neurocardiogenic syncope. However, the evidence against this as a mechanism is now overwhelming. Nowadays, it is suggested that the etiology of the neurocardiogenic syncope is related with hormonal alterations in the central nervous system. Many mechanisms have been implicated involving central and peripheral participation. Recent studies suggest that the central serotonergic system may play an important role in eliciting the vasovagal reaction of the neurocardiogenic syncope by inhibiting sympathetic nervous system. In this article we attempt to review some basic aspects of the central serotonergic system and it role in the regulation of cardiovascular function, present data suggesting its potential role in neurocardiogenic syncope. [García R, Guzmán JC, Silva SY, Zarruk JG, López-Jaramillo P, Morillo CA, Silva FA. The rol of central sero-toninergic system in neurocardiogenic syncope etiology