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"Triage" is a process that enables us to manage clinical risk in order to safely and suitably handle patient flows when demand and clinical needs exceed resources. At present, triage systems that are employed are structured according to five levels of priority. Levels are allocated according to the concept that what is urgent is not always serious and that what is serious is not always urgent. This makes it possible to classify patients according to "degree of urgency", so that the more urgent patients will be attended to first and the rest will be re-evaluated until they are seen by the doctor. The Spanish triage system (SET) and the Manchester triage system (MTS) are the two standardised systems most implemented in our country. We also discuss the system of triage devised in Navarre--integrated in the computerised clinical history--and used in the hospital network of Navarre. All are multidisciplinary systems based on the reasons and urgency of consultation, but not on diagnoses, and are carried out by nursing staff with medical support when required. In addition, they all include monitoring of the quality of the accident and emergency service itself, and can be applied in the outpatient field.

Aim: To determine predictors of frequent chest pain unit (CPU) users and to identify characteristics and outcomes of their CPU visits., Patients and Methods: Observational prospective case-control study. Frequent CPU user was defined by 3 or more CPU visits within the study year. A control patient and a control visit were randomly selected for each case patient and case visit. Demographic, clinical, and outcome variables were collected from medical record and phone interview performed in a 30-day interval. A multivariate logistic regression analysis was used to identify frequent CPU users' predictors., Results: Of 1934 patients presenting during the year, 80 (4.1%) met the definition for case patient. They accounted for 352 (13%) of 2709 CPU visits. Sixty-seven (83.7%) case patients and 71 (88.7%) control patients were contacted. The final predictors were the following: Karnofsky Performance Scale of 70 or lesser (odds ratio [OR], 5.24 [95% confidence interval {CI}, 1.71-16.06]), previous hospitalization (OR, 3.76 [95% CI, 1.49-9.49]), previously known coronary artery disease (OR, 3.72 [95% CI, 1.32-10.52]), and symptoms of depression (OR, 2.98 [95% CI, 1.14-7.78]). Case visits were more likely at night (OR, 2.41 [95% CI, 1.64- 3.52]), generated more diagnostic uncertainty (OR, 2.39 [95% CI, 1.71-3.35]), but did not increase the need of hospital admission., Conclusions: Frequent CPU user is associated with previously known coronary artery disease, previous hospitalization, impaired performance status, and presence of symptoms of depression. They are more likely to arrive on CPU at night and generate more diagnostic uncertainty.

Background and Objective: We aimed: a) to determine changes in patient flow, and in emergency department (ED) effectiveness and quality that may happen depending on the season (winter/non-winter), and b) to analyze effects on those changes when a special winter programme (SWP) of the Pla Integral d'Urgències de Catalunya (PIUC) is applied., Material and Method: We studied 4 weeks of each period: non-winter period, winter control period (without SWP), winter period with SWP. Within the 3 periods, the daily census was taken as a proxy of external pressure, and the number of patients admitted to the hospital from the ED as a proxy of internal pressure. In each period, effectiveness markers--ED occupancy rate, rate of ED patients waiting for a bed, waiting time (WT) and number of patients waiting to be seen (PW), length of stay-- objective quality markers -revisit rate, rate of patients left without being seen, rate of patients left against medical advise (LAMA), and mortality rate-, and subjective quality markers -patient satisfaction with the physician, the nurse, the general ED organization, and level of complaint solution- were recorded., Results: Compared to the non-winter period, in the winter period without SWP the daily census rose by 6% (p = 0.07), and the number of patients admitted 10.8% (p = 0.16). These increases went along with a worsening of almost all effectiveness and quality markers, although only PW (+63%; p < 0.01), WT (+130%; p < 0.001), length of stay (+28%; p < 0.05), rate of patients left without being seen (+97%; p < 0.001) and LAMA (+218%; p < 0.05) reached statistical significance. In the winter period with SWP, the daily census kept stable but the number of patients admitted grew by 18% (p < 0.01). The SWP improved some subjective quality markers (patient satisfaction with the physician and the nurse), but failed to improve any effectiveness or objective quality marker. Some of them got even worse within the SWP period: ED occupancy rate, +20% (p = 0.001); PW, +42% (p < 0.05), and WT, +56% (p < 0.05)., Conclusions: In winter, a worsening of ED effectiveness and quality can be expected. Measures from the SWP prepared by the Administration are unable to correct such deterioration. A profound analysis of the SWP is suggested.

Aim: The aim of the study was to establish a triage flowchart to rule out acute coronary syndrome (ACS) among patients with chest pain (CP) arriving on an Emergency Department (ED)., Patients and Method: This prospective observational study included 1000 consecutive patients with CP arriving on an ED CP unit. Demographic and clinical characteristics along with vital signs were recorded as independent variables. After CP unit protocol completion and 1-month follow-up, patients were classified as (dependent variable) (1) true non-ACS (all noncoronary patients at the first visit that kept this condition when called 1 month later) or (2) true ACS (all the remaining patients). Relationship among variables was assessed by multiple logistic regression analysis. A triage flowchart was obtained from significant variables and applied to patients with CP who were then grouped in "triage non-ACS" and "triage ACS." Validity indexes to exclude ACS for triage flowchart were measured., Results: Variables significantly associated with non-ACS and included in the triage flowchart were age <40 years (odds ratio 3.61, 95% CI 1.63-7.99), absence of diabetes (2.74, 1.53-4.88), no previously known coronary artery disease (5.46, 3.42-8.71), nonoppressive pain (10.63, 6.04-18.70), and nonretrosternal pain (5.16, 2.82-9.42). For the triage flowchart, both specificity and positive predictive value to rule out ACS were 100%., Conclusions: The triage flowchart is able to accurately identify patients with CP not having an ACS. It may help triage nurses make quick decisions on who should be immediately seen and who could safely wait when delays in medical attention are unavoidable. Prospective validation is needed.

Introduction and Objectives: To determine the prevalence and clinical characteristics of non-traumatic chest pain, to assess the quality of treatment provided by an emergency department chest pain unit (CPU), and to provide a theoretical estimate of the size of future CPUs., Methods: This prospective study included 1000 consecutive patients with chest pain seen at a CPU and a second group comprising the remaining patients seen for other complaints. Data on the patients' clinical characteristics, final diagnosis, destination (i.e., admitted or discharged), waiting time, and length of stay were recorded. In the CPU, the door-to-ECG time, and, when referred, the door to needle time and the door-to-balloon time were also recorded. In considering CPU size, the number of chest pain patients and the time to admission or discharge were utilized., Results: Among 22468 visits, the prevalence of chest pain was 4.4%. Compared with other patients, those with chest pain were more frequently male, older, had to wait less time, and were admitted more often. Of the 1000 chest pain patients, 25.9% had acute coronary syndrome (ACS), 64.7% did not, and 9.4% were not diagnosed because exercise testing could not be performed. Patients with ACS were older and had more cardiovascular risk factors, but no gender difference was found. The door-to-ECG time was 10 min, the door to needle time was 26 min, and the door-to-balloon time was 51 min. One CPU stretcher is required for every 13000 emergency department visits per year., Conclusions: The prevalence of chest pain and affected patients' distinct clinical profile support the introduction of emergency department CPUs. Although there were limitations on the use of exercise testing, quality of treatment standards for ACS were achieved.

Background and Objective: Atrial fibrillation is managed in multiple settings by different specialists. We sought to analyze treatment and compliance of the prevailing guidelines of patients with atrial fibrillation attended at different levels of health care and to quantify interventions to correct treatment inadequacies., Patients and Method: We included all adult patients with atrial fibrillation who presented during a 14 day-period to different levels of health care of a tertiary hospital and a related primary care clinic (family physician, cardiologist, emergency department, hospitalization). In all of them, clinical and epidemiological data in relation to atrial fibrillation, and all data referring to treatment and compliance of guidelines, were recorded prospectively., Results: 293 patients were included. Clinical and epidemiological data were similar in the different settings. A great diversity in atrial fibrillation treatment was observed. In 30 and 33% of the patients, antiarrhythmic and antithrombotic treatment, respectively, did not meet the recommendations of the prevailing guidelines. The adequacy was inferior in primary care. The adequacy percentages increased slightly after the medical attention (2 and 3% respectively, p non significant) with no differences in this increase between the different settings., Conclusions: There are no epidemiological differences between patients with atrial fibrillation treated at different levels of health care. An important number of patients do not follow the recommendations of the prevailing guidelines. There is a clear medical abstention in incorrectly treated cases.

Background and Objective: To find out if the daily emergency department (ED) census and daily ED admittances can accurately be foreseen based on the number of visits arrived on ED within the first shift hours., Patients and Method: For 6 consecutively months, the number of ED visits from 6 AM to 10 AM (early visits), and from 10 AM to next day 6 AM (daily ED census) was recorded, along with the number of both daily hospital and ED admittances from 6 AM to 6 AM. The analysis was performed for the ED as a whole, and for each one of its sections., Results: A significant direct correlation was seen between the early visits and daily ED census. This relationship was even greater as considered the ED as a whole (R2 = 0.25; p < 0.001). A direct correlation was also found between daily ED census and daily admittances (R2 = 0.19; p < 0.001)., Conclusions: The number of early ED visits is an important tool to accurately predict the daily ED census and the number of in-hospital beds needed for ED patients.

Background and Objective: To determine the effect that the lack of inhospital beds exerts on emergency department performance., Material and Method: Two different time periods with comparable daily census, but significantly different bed availability. Variables assessed were general emergency department performance markers, emergency department effectiveness markers and objective and subjective quality markers., Results: All variables got worse within lower bed availability period, and reached a change magnitude between 0% and 300% when compared with control period. However, a statistical difference was only achieved in emergency department occupation rate (+14%; p < 0.001), rate of patients waiting to be admitted (+100%; p < 0.001), patients waiting to be seen (+60%; p < 0.01), waiting time to be seen (+83%; p < 0.001), time to employed for first medical assessment and treatment (+44%; p < 0.01), and patients left without being seen (+90%; p < 0.05)., Conclusions: The lack of inhospital beds for patients admitted from the emergency department leads to a remarkable worsening in its function and performance.

Background and Objective: Several thousands deaths were attributed to a heatwave during the summer of 2003 in Europe. The aim of this study was to analyze its consequences in an emergency department., Patients and Method: We performed a descriptive observational study of the patients admitted to our emergency unit between 15 July and 31 August, 2003. We also carried out a comparative study of these patients with those admitted during the same period of 2002., Results: A total of 5197 patients were admitted in our unit during the summer of 2003, in comparison with 4672 in the same interval in 2002. An increase in rates of total fever (17% versus 12%; p < 0.001), non-infectious fever (29% versus 26%; p < 0.001), decompensation of a chronic cardiovascular or respiratory disease (14% versus 11%; p < 0.001), admission (28% versus 22%; p < 0.001), and mortality (2% versus 1%; p < 0.001) were registered during the summer of 2003, in comparison with the previous year. A multivariate study showed a higher risk of death in patients older than 70 years (p < 0.01), in fragile dependent people (p < 0.05), and upon the presence of abnormal blood levels of creatinine (p < 0.05) on arrival at the emergency department. We also found an association between daily maxim temperature and number of daily emergency visits (R2 = 0.15; p < 0.001), total percentage of patients with fever (R2 = 0.26; p < 0.001), percentage of patients with non-infectious fever (R2 = 0.07; p = 0.01), percentage of decreases (R2 = 0.04; p < 0.05), and percentage of hospital admissions (R2 = 0.15; p < 0.001)., Conclusions: The summer 2003 heatwave resulted in an elevation of the total number of emergency visits and hospital admissions, and higher mortality and morbidity rates, especially in old people. In the future, preventive measures must be taken to limit the health consequences of any heatwaves to come.

Background and Objectives: To know the effect that the presence of a general practitioner (GP) has on emergency department's effectiveness, efficiency and health care., Patients and Method: Prospective interventional study carried out in the emergency medicine unit fast track area (FTA), which is ideally opened from 8 am to 12 am, and staffed by 2 residents., Intervention: 8 resident hours (from 4 pm to 12 am) were substituted by 8 GP hours. The study period was August 2002 (GP presence), and the control period, October 2002. From each period, 10 days and 100 patients were randomly selected. From each day, FTA census (P), percentage of revisits and patients leaving without being seen, elapsed time to FTA actual closing (OT), percentage of patients moved to the observation area, and percentage of admissions were recorded. From each patient, epidemiological and clinical characteristics, waiting time to be seen (WT), number of tests performed, elapsed time to treatment (TT), and length of stay (LOS) were collected along with the number of patients finally discharged without hospital specialist consultation and those discharged with no test ordered. To assess perceived care quality, a telephone survey was performed. Three effectiveness indexes were defined and determined: P/WT (E1), P/OT (E2), and perceived care quality/perceived WT (E3). Finally, fixed and variables costs (C) from both periods were calculated, and cost-effectiveness analysis for each effectiveness index and period performed., Results: Periods showed no differences regarding daily census and patient characteristics. In the study period (GP presence), all time variables significantly improved: 20% reduction in WT, 25% in TT, 36% in LOS, and 17.5% in OT. A decrease in the number of tests ordered (41% less), in the percentage of patients moved to the observation area (78% less), and in the revisit rate (75% less) was also noted. Finally, E1 improved in 77% and E2 in 51%. Cost-effectiveness analysis clearly supported the study period, showing a decrease in C/E1 (55% less), in C/E2 (33% less), and in C/E3 (6% less). From the telephone survey, no differences between periods were detected except a perceived WT in the study period lower than that in the control period., Conclusions: The presence of a GP in a FTA leads to an improvement in the effectiveness and quality of care received by attended patients. In addition of these important features, this presence is also efficient. Therefore, it is an intervention that could be taken into account by administrators to better manage emergency departments.

Background and Objective: The PROCES (Programa de Reanimació Cardiopulmonar Orientat a Centres d'Ensenyament Secundari) program is aimed at teaching basic cardiopulmonary resuscitation (b-CPR) to teenagers within high school. Our aim was to analyze the results obtained from the pilot program., Subjects and Method: PROCES was splitted in 7 sessions: 5 of them (5 hours) were taught by teachers at high school and 2 of them (4 hours, including how to perform b-CPR) were taught by emergency physicians. To assess the degree of students' learning, they were administered a 20-question test before and after the program. Epidemiological characteristics and students' opinions (all them were requested to rate the program from 0 to 10) were also collected., Results: Students were 14 years-old in 38%, 15 in 38% and 16 or more in 24%. Before PROCES, the mean mark (over 20 points) was 8.5 (2.4). After PROCES, marks improved up to 13.5 (3.2) (p < 0.001). Participants who had previously taken a first-aid course or were in the 4th course obtained significantly better marks than the rest. These differences disappeared after PROCES completion. Students rated the theoretical part as 7.9 (1.1), the skill part as 8.2 (1.2), and the emergency physicians classes as 8.4 (1.1)., Conclusions: PROCES is an useful tool for teaching and improving teenagers' knowledge and skills in b-CPR, with no exceptions associated with teenagers' characteristics.

Study Objective: We compare effectiveness, adverse effects, and recovery times of propofol, etomidate, and midazolam (with and without flumazenil) for cardioversion in the emergency department (ED)., Methods: Thirty-two hemodynamically stable adult patients undergoing cardioversion in the ED were randomly assigned to receive etomidate (n=9), propofol (n=9), midazolam (n=8), or midazolam followed by flumazenil (n=6). For all patients, we measured induction time, awakening time, total recuperation time, global time, and adverse effects. Arterial pressure, cardiac and respiratory rate, and peripheral oxygen saturation were monitored throughout the procedure. Descriptive and nonparametric tests were used., Results: Demographic data were similar in all groups. Deep sedation and successful cardioversion were achieved in all cases. Hemodynamic assessment at baseline, after induction, after cardioversion, and at recovery demonstrated no significant difference between the 4 groups. Induction time was short in all groups. Awakening time was longer in the midazolam group (median 21 minutes, range 1 to 42 minutes) compared with that of the other groups (etomidate group: median 9.5 minutes, range 5 to 11 minutes; propofol group: median 8 minutes, range 3 to 15 minutes; midazolam/flumazenil group: median 3 minutes, range 2 to 5 minutes), and the same occurred with total recuperation time (etomidate group: median 14 minutes, range 5 to 20 minutes; propofol group: median 10 minutes, range 5 to 15 minutes; midazolam group: median 45 minutes, range 20 to 60 minutes; midazolam/flumazenil group: median 5 minutes, range 2 to 90 minutes). All patients in the midazolam/flumazenil group but 1 became resedated after flumazenil was discontinued. Four patients who had received etomidate exhibited myoclonus, which was pronounced and seizure-like in 1 case., Conclusion: Four sedative regimens (propofol, etomidate, midazolam, and midazolam/flumazenil) were uniformly effective in facilitating ED cardioversion in hemodynamically stable adults. Propofol was well tolerated and lacked the myoclonus, prolonged sedation, and resedation noted with the latter 3 respective groups. Larger studies are needed to generalize these conclusions.

Background and Objective: Emergency department (ED) overcrowding has been increasing over the last years. The aims are to define ED overcrowding, and to determine and quantify which factors explain it., Patients and Method: For 3 consecutive weeks throughout 3 years (2000-2002), we recorded every 3-hour period, the arrivals, the occupancy rate (OR) of patients in ED, in first aid area (FAA), and in observation area (OA) according to the reason for their stay. The data was subjected to multiple logistic regression analysis including as a dependent variable non overcrowding/overcrowding for each area (ED, FAA, and OA). Overcrowding was defined as an OR >= 100%. Models from the three areas were calculated according to goodness of fit and were discriminated by ROC methodology. Models were set up after randomizing data in two groups: selection set (88% of data) and validation set (12% of data)., Results: Variables associated with overcrowding in the ED model were OR of patients waiting for test results, for a bed going to be left, to find a bed, for test performed out of ED, and for outcome. In the FAA model, they were OR of patients being seen, and waiting for test results. Finally, in the OA model they were OR of patients waiting for a bed going to be left, to find a bed, for test performed out of ED, and for outcome. For all models sensitivity and specificity were greater than 85%, with a ROC area greater than 0.97. We did not find any relationship between number of arrivals and overcrowding for none model. Results were corroborated on the validation data set., Conclusions: Patients remaining in the ED due to factors related to both hospital (waiting for a bed going to be left, or to find a bed), and ED itself (waiting for outcome) are the main reason for ED overcrowding.

Background: The goal of this study was to evaluate the relative association of several components of blood pressure (BP), as measured in the office and by ambulatory monitoring (ABPM), with clinically useful indicators of target organ damage and cardiovascular events (CE) in essential hypertensive patients., Patients and Method: We retrospectively included 390 hypertensives (55% men; mean age: 56 years) between 1989 and 1998. All them had a baseline office BP measurement and a valid 24-hour ABPM record, both performed while the patient was free of antihypertensive therapy. Estimates of target organ damage included electrocardiographic indexes of left ventricular hypertrophy (Cornell and Sokolow-Lyon), serum creatinine, 24-hour urine protein excretion and creatinine clearance. Multiple linear regression and logistic regression analyses were used to evaluate the relationship between BP and target organ damage or CE., Results: Forty-nine patients had CE (26 stroke, 18 myocardial infarction and 5 both). The BP parameter correlating better with cardiovascular events was office pulse pressure (multivariate odds ratio: 1.03; CI 95%: 1.00-1.05; p = 0.0095). Nevertheless, cardiac growth indexes correlated better with ABPM measurements. In fact, Cornell index correlated with night-time systolic BP (standardized regression coefficient beta: 0.260; p < 0.001) and Sokolow-Lyon index correlated with day-time systolic BP ( beta: 0.257; p < 0.001). Creatinine clearance inversely correlated with night-time pulse pressure ( beta: 0.122; p = 0.017) while proteinuria correlated better with 24-hour systolic BP ( beta: 0.390; p < 0.001)., Conclusions: Whereas office BP (especially pulse pressure) is associated with the development of CE, ABPM estimates show a better association with target organ damage, especially systolic and pulse pressures.

Numerous epidemiologic and clinical studies have demonstrated a clear relationship between high salt intake and blood pressure. However, the mechanisms of a salt-induced increase in blood pressure--a phenomenon known as salt sensitivity--and the heterogeneity of this effect are far from being completely understood. Endothelial dysfunction, and especially the nitric oxide system, is implicated in both experimental and clinical hypertension. Animal studies indicate that endogenous nitric oxide plays an important role in renal hemodynamics and sodium homeostasis, inducing renal vasodilation and natriuresis. Studies of essential hypertensive patients have also suggested that both high salt intake and salt sensitivity are associated with impaired endothelial function. Although there are many hypotheses concerning the nature of salt sensitivity, clinical data indicate that salt-sensitive patients may be unable to up-regulate the production of nitric oxide in response to salt intake. This endothelial dysfunction, which is more frequent in salt-sensitive than in salt-resistant essential hypertensive patients, may partially explain the blood pressure increase in response to salt intake and may underlie the more pronounced target organ damage and cardiovascular risk in salt-sensitive patients., ((c) 2002 Le Jacq Communications, Inc.)

We analyzed the association between salt sensitivity in essential hypertension and 8 genetic polymorphisms in 6 genes of the renin-angiotensin aldosterone system. Seventy-one patients with essential hypertension were classified as salt sensitive or salt resistant by means of the 24-hour ambulatory blood pressure (BP) change to high salt intake. The polymorphisms evaluated correspond to the following genes: ACE (I/D), angiotensinogen (M235T), angiotensin II type 1 receptor (A1166C), 11beta-Hydroxysteroid dehydrogenase type 2 (11betaHSD2) (G534A), aldosterone synthase (C-344T and Intron 2 conversion), and the mineralocorticoid receptor (G3514C and A4582C); all were determined using standard polymerase chain reaction methods. Thirty-five patients (49%) were classified as salt sensitive. We analyzed the BP response to high salt intake among genotypes and found a significant association for ACE I/D and 11betaHSD2 G534A polymorphisms. Patients homozygous for the insertion allele of the ACE gene (II) had a significantly higher BP increase with high salt intake than did patients homozygous for the deletion allele (DD). Heterozygous patients (ID) exhibited an intermediate response. The prevalence of salt-sensitive hypertension was also significantly higher (P=0.003) in II (68%) and DI patients (59%) compared with DD hypertensives (19%). With respect to 11betaHSD2 G534A, patients with the GG genotype had a significantly higher systolic BP increase with high salt intake than did GA patients. In addition, plasma renin activity suppression in response to high salt was significantly greater in GA patients than in GG patients. The prevalence of salt-sensitive hypertension was 14.3% in GA patients and 50.8% in GG patients (P=0.067). In conclusion, the I allele of ACE I/D polymorphism is significantly associated to salt-sensitive hypertension. The BP response to high salt intake was different among genotypes of ACE I/D and 11betaHSD G534A, suggesting that these polymorphisms may be potentially useful genetic markers of salt sensitivity.

The genetic functional variant C for T in position 825 of the gene encoding G protein beta 3 subunit, GNB3, has been associated with enhanced G protein activation, cell growth and proliferation. This phenotype is associated with enhanced G protein activation and Na(+)-H+ exchanger activity in cells from hypertensive patients. Salt sensitivity affects approximately 50% of hypertensive patients and constitutes an intermediate phenotype determined in part by genetic factors. An association between enhanced Na(+)-H+ exchanger activity and salt sensitivity has been previously reported. The aim of the present study was to investigate the possible association between the G protein polymorphism and salt sensitivity in patients with essential hypertension. A total of 46 patients were studied and classified according to their blood pressure response to a change in sodium intake from low (20 mmol/day) to high (260 mmol/day) into salt sensitive (SS) (n = 20) and salt resistant (SR) (n = 26). GNB3 polymorphism was determined by PCR of genomic DNA and restriction digestion with BseDI. The genotypes distribution among the SS hypertensives was: 8 CC and 12 CT + TT, whereas in SR was: 10 CC and 16 CT + TT (p = 0,577). 24 h mean blood pressure response to salt in the whole group was not different among the different genotypes: CC 4.1 +/- 5.4 mmHg compared to CT + TT 2.9 +/- 6.3 mmHg (p = 0.51). There were no significant differences in the salt induced changes in plasma renin activity, aldosterone, ANP or noradrenaline among the different genotypes. These results indicate that the GNB3 C825T polymorphism has no major influence on the pressor response to salt in essential hypertension and therefore do not support its usefulness as an early genetic marker of salt sensitivity in this disease.

The aim of the present study was to evaluate the effects of the level of salt intake on endothelium-derived factors in a group of patients with essential hypertension. A group of 50 patients with essential hypertension who had never been treated for the condition were placed on a low-sodium (50 mmol/day), low-nitrate (400 micromol/day) diet, which was supplemented, in a single-blind fashion, with placebo tablets for the first 7 days and then with NaCl tablets (200 mmol/day) for a further 7 days (total sodium intake 250 mmol/day). At the end of both periods, 24-h ambulatory blood pressure monitoring was performed. In addition, plasma levels and 24-h urinary excretion of nitrites plus nitrates and cGMP were measured, along with plasma levels of endothelin. A high salt intake promoted significant decreases in plasma levels of nitrites plus nitrates (from 41.0+/-2.1 to 32.8+/-1.8 nmol/ml; P<0.001), 24-h urinary nitrate excretion (from 417+/-36 to 334+/-37 micromol/24 h; P=0.045) and plasma endothelin levels (from 5.6+/-0.3 to 4.6+/-0.3 pg/ml; P=0.007). The plasma concentration and 24-h urinary excretion of cGMP were not altered significantly by a high salt intake. We did not find any relationship between endothelium-derived products and 24-h mean blood pressure, at either low or high salt intakes, or between changes induced by the high-salt diet. A high salt intake also induced significant decreases in plasma renin activity, angiotensin II and aldosterone, and a significant increase in atrial natriuretic peptide. We conclude that a high salt intake decreases the plasma concentration and urinary excretion of nitrates and plasma levels of endothelin in patients with essential hypertension, suggesting that the level of salt intake may affect endothelial cell function. However, these alterations are not correlated with changes in blood pressure induced by the high salt intake.

Background: To determine the effects that the reform of an emergency department (ED) have on efficacy, health care quality and efficiency., Material and Method: Reforms consisted of 50% and 34% increases in structural and human resources, respectively. Roles of each ED member were redetermined, new assistance pathways were implemented, and the relationship between ED and the remaining hospital departments was reassessed. As efficacy markers, we determined the number of patients waiting to be attended (Pesp), the waiting time of patients to receive medical assistance (T(esp)),and the total waiting time of patients staying in the ED (T(total)). As health-care quality markers, we determined the percentage of patients leaving ED without having been visited by a physician(IPNV), the percentage of patients who were visited again (IPR),and the percentage of mortality (IPF). We also quantified the number of visits to the ED. All these data were obtained daily over 3 weeks, before (February 1999) and after (February 2000)the reforms. Effectiveness was estimated from the ratio P(total)/T(esp)(E1) and P(total)/P(esp) (E2). Costs were recorded for both periods and a cost-effectiveness analysis was performed to study the efficiency., Results: In 2000, the number of visits increased by +12% (CI 95%: 2% to 22%). Despite this increase, we observed an improvement of most efficacy and health-care quality markers after the ED reforms. E1 increased by 996% (CI 95%: 335% to 1,658%) and E2 increased by 186% (CI 95%: -23%to 395%). Cost-effectiveness analysis showed 70% (CI 95%: 33%to 107%) and 56% (CI 95%: 18% to 94%) increases regarding E1 and E2, respectively, after the reforms., Conclusions: Providing ED with the necessary resources leads to an objective improvement of its efficacy and health-care quality and, consequently, the service and quality perceived by users improve. Despite the total cost increase after the ED reforms, efficiency also improves.

We evaluated the association of a common polymorphism in gammaENaC, consisting in a C to G transversion in codon 649, with essential hypertension and to the pressor response to salt in whites. Two hundred fifteen essential hypertensive patients, and 137 normotensive controls were genotyped for the gamma649 ENaC polymorphism by polymerase chain reaction method and diagnostic restriction enzyme digestion. The genotype distribution of the gamma649 ENaC polymorphism in the hypertensives, 129 CC (60%) and 86 CG/GG (40%) was not significantly different from that of the control group, 84 CC (61%) and 53 CG/GG (39%) (P = .81). Salt sensitivity was assessed in a group of 48 patients by 24-h mean blood pressure response to changes in salt intake. Nineteen patients were diagnosed as salt sensitive, whereas 29 had salt-resistant hypertension. The gamma649 ENaC genotype distribution in salt-sensitive patients was 12 CC (63%) and 7 CG/GG (37%), not significantly different from the distribution in the salt-resistant group, 19 CC (65%) and 10 CG/GG (35%), P = .87. The changes in systolic, diastolic, and mean blood pressure as measured by ambulatory blood pressure monitoring, and in plasma renin activity and plasma aldosterone induced by high salt diet were not different among the gamma649 ENaC genotypes. In the present study we found no association between the gamma649 ENaC polymorphism and essential hypertension or salt sensitivity. Although these data do not support a major causative role for this polymorphism, we cannot exclude that a functional mutation elsewhere in ENaC might be associated with essential hypertension.

Ingestion of paraquat is the most common cause of fatal pesticide poisoning. Liver involvement in acute paraquat poisoning is self-limited and usually consists of cholestasis. However, long-term hepatic effects after paraquat exposition have not been described up to now, probably because of the high mortality rate of this acute poisoning. We report the case of an agricultural worker who developed persistent cholestasis after an episode of acute paraquat poisoning through skin absorption.

This study aims to evaluate the clinical and biochemical profile associated with the presence of microalbuminuria in a group of essential hypertensive patients referred to a hypertension clinic. A total of 188 non-diabetic, untreated essential hypertensive patients (100 men, 88 women) aged 55.8 +/- 11.7 years are studied. Urinary albumin excretion was determined in two 24-h urine collections. Clinical and biochemical evaluations and 24-h ambulatory blood pressure (BP) monitoring were performed at baseline. Forty-two patients (22.3%) showed an increased urinary albumin excretion rate (20-200 micrograms/min). These patients showed significantly higher values (P < 0.01) for 24-h, daytime and night-time systolic and diastolic BP, compared with essential hypertensives with normal urinary albumin excretion. However, nocturnal reduction in BP did not differ between the groups. Furthermore, patients with microalbuminuria showed significantly higher (P < 0.01) creatinine, serum uric acid and triglycerides, as well as lower high-density lipoprotein (HDL)-cholesterol. In a multiple logistic regression analysis, a 24-h systolic BP > 140 mmHg (odds ratio: 3.19; 95% confidence interval [CI 95%]: 1.44-7.06) and a serum creatinine > 88 mumol/L (odds ratio: 3.08; CI 95%: 1.39-6.84) were the two factors associated independently with increased urinary albumin excretion. We conclude that, in essential hypertensive patients, the presence of microalbuminuria is associated with elevated BP, but not with its circadian pattern. Likewise, microalbuminuria is associated with the degree of renal impairment, and with increased uric acid and triglycerides and decreased HDL-cholesterol.

1. The aim of the study was to detect differences between salt-sensitive and salt-resistant hypertensive patients in the response of the renin-aldosterone axis, plasma noradrenaline and atrial natriuretic peptide to high salt intake. 2. Fifty essential hypertensive patients followed 2 weeks of a standard diet with 20 mmol of NaCl daily, supplemented by placebo tablets for the first 7 days and by NaCl tablets for the last 7 days, in a single-blind fashion. Salt sensitivity was defined as a significant rise (P < 0.05) in 24 h mean blood pressure obtained by ambulatory blood pressure monitoring from the low- to the high-salt period. Biochemical and hormonal measurements were performed on the last day of both periods. 3. Twenty-two (44%) patients fulfilled criteria of salt-sensitive hypertension, whereas the remaining 28 (56%) were considered salt-resistant. High salt intake promoted a significant decrease (P < 0.05) in plasma creatinine, potassium, glucose, cholesterol, low-density lipoprotein-cholesterol, triacylglycerols, uric acid and plasma renin activity, and a significant increase in plasma atrial natriuretic peptide and 24 h urinary calcium excretion. The direction of these changes did not differ between salt-sensitive and salt-resistant patients. Salt-resistant hypertensive patients exhibited a significant decrease in plasma aldosterone induced by high salt intake (from 446 +/- 35 to 226 +/- 35 pmol/l; P < 0.001), whereas this parameter was not significantly modified in salt-sensitive patients (from 485 +/- 76 to 364 +/- 83 pmol/l; P not significant). Salt-sensitive patients showed an increase in plasma noradrenaline after high salt intake (from 1.15 +/- 0.11 to 1.56 +/- 0.14 nmol/l; P < 0.05), whereas salt-resistant patients presented a decrease in this parameter (from 1.48 +/- 0.08 to 1.12 +/- 0.08 nmol/l; P < 0.05). The change in plasma noradrenaline was directly correlated with the change in mean blood pressure induced by high salt intake (r = 0.479; P = 0.003). 4. We conclude that the increase in blood pressure induced by high salt intake in salt-sensitive patients is associated with a stimulation of the sympathetic nervous system and a blunted decrease in plasma aldosterone. Conversely, changes in renal function, electrolyte excretion and plasma concentrations of atrial natriuretic peptide induced by high salt intake seem to be similar in both salt-sensitive and salt-resistant patients.