No abstract

Chest pain accounts for much of the rising numbers of emergency admissions, but in-patient assessment is not necessarily the best way of dealing with these patients. We ran a 'rapid-assessment chest pain clinic' to provide an alternative route of assessment, and audited its outcome. General practitioners referred patients with recent-onset chest pain, increasing chest pain, chest pain at rest, or other chest pain of concern, on the understanding that they would be seen within 24 h. During 8 1/2 months, 334 patients were referred and 317 patients were seen, most of whom had exercise electrocardiography. A median of 6 months later, 278 patients were personally contacted to determine outcome. Of these, 18% had been admitted immediately with acute coronary syndromes, and 49% had been diagnosed as non-coronary chest pain (none of whom subsequently infarcted or died). Continuing symptoms were infrequent, and satisfaction was high, although 13% of patients had been revascularized. A significant number of patients required immediate admission and/or ultimate revascularization, but many more did not. The majority of these patients had non-coronary chest pain, and this diagnosis was substantiated by their excellent outcome and (in some cases) by further investigation.

Berdasarkan data profil kesehatan Indonesia tahun  2015, cakupan program Sanitasi Total Berbasis Masyarakat (STBM) di Indonesia memang masih rendah. Buruknya kondisi sanitasi ini, berdampak pada masih tingginya kasus water borne disease seperti diare. Selain itu, rendahnya akses sanitasi dasar mengakibatkan  tingginya jumlah balita stunting atau pendek. Salah satu faktor yang dapat menyebabkan rendahnya cakupan sanitasi dasar ini adalah pengetahuan masyarakat tentang sanitasi yang masih rendah. Tujuan penelitian ini adalah untuk menganalisis pengaruh media buku saku terhadap pengetahuan tentang sanitasi lingkungan pada kader kesehatan Desa Cranggang. Jenis penelitian ini adalah pra eksperimen, dengan desain one group pre test post test. Jumlah sampel dalam penelitian ini adalah 20 sampel, dengan instrument yang digunakan untuk pengambilan data adalah kuesioner. Hasil penelitian menunjukan rata-rata nilai pre test responden adalah 77, sedangkan rata-rata skor post test adalah 88. Hasil analisis statistik menggunakan uji regresi linier diperoleh nilai p value 0,0001 yang artinya terdapat pengaruh yang signifikan pemberian buku saku terhadap pengetahuan tentang sanitasi lingkungan pada kader kesehatan di Desa Cranggang, dengan nilai koefisien 0,598. Kata Kunci : Buku Saku, Sanitasi, Pengetahuan

A significant proportion of patients required prolonged multiple organ support or complex ventilation. Case fatality compared favourably to other recent outbreaks in Europe. Access to rapid diagnostic tests and prompt antibiotic therapy may have mitigated the impact of pre-existing poor health among those affected.

SUMMARYThis case describes the unexpected survival of an adult man who presented to the emergency department with hypovolaemic shock secondary to a splenic haemorrhage. Before surgery he had a pH 6.527, base excess (BE) −34.2 mmol/l and lactate 15.6 mmol/l. He underwent a splenectomy after which his condition stabilised. He was managed in the intensive care unit postoperatively where he required organ support including renal replacement therapy but was subsequently discharged home with no neurological or renal deficit. Although there are case reports of patients surviving such profound metabolic acidosis these have mainly been cases of near drowning or toxic alcohol ingestion. To the best of our knowledge this is the first reported case of survival after a pH of 6.5 secondary to hypovolaemic shock. CASE PRESENTATIONA 65 year old man presented to the emergency department after a collapse at home. There had been no preceding symptoms or illness. He had a past medical history of atrial fibrillation, gout and acne rosacea and his drugs comprised digoxin, aspirin, omeprazole and oxytetracycline. He did not receive warfarin.On initial assessment he was shocked with cool peripheries and hypotension, in atrial fibrillation with a heart rate of 90 and a blood pressure of 80/40 mm Hg. He was apyrexial with no evidence of cardiac failure and no complaints of chest pain. He had mild, diffuse tenderness at his epigastrium but no peritonism. There was no evidence of gastrointestinal blood loss.Routine blood investigations showed a raised white cell count at 16.0×10 9 /l and normal haemoglobin of 12.6 g/dl. Venous blood gas analysis showed a lactate level of 5.4 mmol/l but was otherwise unremarkable.He received 3 litres of 0.9% NaCl over the next 2 h with no improvement in his haemodynamic profile. He then rapidly deteriorated with severe abdominal pain and increasing agitation. A plan to obtain an abdominal CT scan was abandoned owing to haemodynamic instability and agitation. An abdominal ultrasound scan in the resuscitation room showed minimal free fluid and no evidence of an abdominal aortic aneurysm or solid organ abnormality. Treatment was started with an adrenaline infusion and he underwent rapid sequence induction and intubation in the emergency department. After resuscitation from a brief pulseless electrical activity (PEA) cardiac arrest he was transferred to theatre for an emergency laparotomy. On arrival in theatre he had a profound metabolic acidosis with a pH of 6.527 (hydrogen ion 313 nmol/l), base excess (BE) −34.2 mmol/l and lactate 15.6 mmol/l, see figure 1. At this point he had a blood pressure of 58/32 mm Hg, heart rate 150 bpm, arterial oxygen saturation (SaO 2 ) 90% on fractional inspired oxygen (FiO 2 ) 0.98 and core temperature of 34°C. He continued with an adrenaline infusion.Laparotomy showed marked bleeding from the distal splenic artery. This was ligated and a splenectomy was performed, although the spleen itself appeared to be intact. After this the brisk bleeding settled and the abdomen was closed...