Pediatric televisits and telephone triage: impact on use of a hospital emergency department

Objetivos: analizar las características de las teleconsultas y triajes telefónicos pediátricos atendidos por CatSalut Respon y describir su impacto sobre la actitud y la decisión final de los padres-usuarios de acudir o no a urgencias. Método: estudio observacional transversal. Durante la teleconsulta los pacientes se clasificaron según los niveles del sistema español de triaje. Aquellos que fueron derivados a urgencias se volvieron a clasificar en el hospital, y se compararon los niveles de triaje. Posteriormente, se realizó una llamada de verificación. Se recogieron variables sociodemográficas y clínicas. Resultados: se analizaron 370 teleconsultas, fundamentalmente no urgentes (n = 300; 81%). Un 20,3% (n = 75) fueron derivadas a urgencias. La fiebre (p = 0,002) y las dudas de medicación (p < 0,001) fueron motivos significativos de teleconsulta no urgente. Casi un 46% de los casos con niveles de gravedad altos en el triaje de la llamada también fueron clasificados con niveles de gravedad altos en el triaje posterior realizado en el servicio de urgencias hospitalario, mostrando una concordancia moderada. Más del 50% de los padres tenían intención de acudir a urgencias antes de la teleconsulta y un 46% cambiaron de actitud tras realizar esta llamada. Conclusiones: fiebre y dudas de medicación fueron motivos estadísticamente significativos de teleconsulta no urgente. La consulta telefónica produjo un cambio de actitud en casi la mitad de los padres

The personalized advantage index: Translating research on prediction into individualized treatment recommendations. A demonstration

Background: Advances in personalized medicine require the identification of variables that predict differential response to treatments as well as the development and refinement of methods to transform predictive information into actionable recommendations. Objective: To illustrate and test a new method for integrating predictive information to aid in treatment selection, using data from a randomized treatment comparison. Method: Data from a trial of antidepressant medications (N = 104) versus cognitive behavioral therapy (N = 50) for Major Depressive Disorder were used to produce predictions of post-treatment scores on the Hamilton Rating Scale for Depression (HRSD) in each of the two treatments for each of the 154 patients. The patient's own data were not used in the models that yielded these predictions. Five pre-randomization variables that predicted differential response (marital status, employment status, life events, comorbid personality disorder, and prior medication trials) were included in regression models, permitting the calculation of each patient's Personalized Advantage Index (PAI), in HRSD units. Results: For 60% of the sample a clinically meaningful advantage (PAI≥3) was predicted for one of the treatments, relative to the other. When these patients were divided into those randomly assigned to their "Optimal" treatment versus those assigned to their "Non-optimal" treatment, outcomes in the former group were superior (d = 0.58, 95% CI .17-1.01). Conclusions: This approach to treatment selection, implemented in the context of two equally effective treatments, yielded effects that, if obtained prospectively, would rival those routinely observed in comparisons of active versus control treatments. © 2014 DeRubeis et al

Feline Leukemia Virus and Other Pathogens as Important Threats to the Survival of the Critically Endangered Iberian Lynx (Lynx pardinus)

BACKGROUND: The Iberian lynx (Lynx pardinus) is considered the most endangered felid species in the world. In order to save this species, the Spanish authorities implemented a captive breeding program recruiting lynxes from the wild. In this context, a retrospective survey on prevalence of selected feline pathogens in free-ranging lynxes was initiated. METHODOLOGY/ PRINCIPAL FINDINGS: We systematically analyzed the prevalence and importance of seven viral, one protozoan (Cytauxzoon felis), and several bacterial (e.g., hemotropic mycoplasma) infections in 77 of approximately 200 remaining free-ranging Iberian lynxes of the Doñana and Sierra Morena areas, in Southern Spain, between 2003 and 2007. With the exception of feline immunodeficiency virus (FIV), evidence of infection by all tested feline pathogens was found in Iberian lynxes. Fourteen lynxes were feline leukemia virus (FeLV) provirus-positive; eleven of these were antigenemic (FeLV p27 positive). All 14 animals tested negative for other viral infections. During a six-month period in 2007, six of the provirus-positive antigenemic lynxes died. Infection with FeLV but not with other infectious agents was associated with mortality (p<0.001). Sequencing of the FeLV surface glycoprotein gene revealed a common origin for ten of the eleven samples. The ten sequences were closely related to FeLV-A/61E, originally isolated from cats in the USA. Endogenous FeLV sequences were not detected. CONCLUSIONS/SIGNIFICANCE: It was concluded that the FeLV infection most likely originated from domestic cats invading the lynx's habitats. Data available regarding the time frame, co-infections, and outcome of FeLV-infections suggest that, in contrast to the domestic cat, the FeLV strain affecting the lynxes in 2007 is highly virulent to this species. Our data argue strongly for vaccination of lynxes and domestic cats in and around lynx's habitats in order to prevent further spread of the virus as well as reduction the domestic cat population if the lynx population is to be maintained

Pediatric televisits and telephone triage: impact on use of a hospital emergency department

Objectives: To analyze the characteristics of remote telephone consultations (televisits) and triage of pediatric emergencies attended by the 24-hour emergency service of Catalonia (CatSalut Respon), and to describe the impact of televisits on callers' decisions about whether or not to come to the emergency department and their opinion of the call service. Material and methods: Observational cross-sectional study. During the call, cases were classified according the Spanish and Andorran triage system. Patients who were sent to the hospital underwent triage again, and the 2 assigned triage levels were compared. The families were later called to check data and ask their opinion of the service. Sociodemographic and clinical data related to the cases were recorded. Results: A total of 370 televisits were made. Most cases (300, 81%) were not emergencies. Seventy-five callers (20.3%) were advised to go to an emergency department. Fever (P = .002) and questions about medication (P < .001) were the problems significantly associated with nonurgent cases. Nearly 46% of the cases classified as serious during telephone triage were also considered serious when the child was brought to the emergency department. The rate of agreement between the 2 triage levels was moderate. Over half the parents stated they had intended to go to the hospital before calling the service; 46% changed their mind based on the call. Conclusion: Fever and questions about medication were significantly associated with televisits for nonurgent cases. Nearly half the parents changed their mind about going to the emergency department after a televisit

613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review

Background Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion. Methods Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011. Results We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy. Conclusions Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture