Publications by authors named "Guillermo Burillo-Putze"

95 Publications

Impact of co-ingestion of ethanol on the clinical symptomatology and severity of patients attended in the emergency department for recreational drug toxicity.

Am J Emerg Med 2021 Aug 23;50:422-427. Epub 2021 Aug 23.

Department of Physical Medicine and Pharmacology, Universidad de La Laguna, Tenerife, Spain. Electronic address:

Objective: Investigate whether there are differences in the drugs involved, symptomatology and severity of drug intoxication in patients with co-ingestion of alcohol attended in hospital emergency departments (ED).

Method: Patients attended in 11 Spanish EDs due to drug intoxication were included. Sociodemographic and clinical characteristics were collected. A combined adverse event of cardiorespiratory arrest, need for intubation, and admission to intensive care or death was considered as the primary indicator of severity. The symptomatology and severity were compared adjusted for age, sex and type of drug based on whether or not ethanol had been co-ingested.

Results: 3925 patients (alcohol co-ingestion: 2290, 58.3%) with a mean age of 33 (±11) years were included, and 25% were women. Co-ingestion of alcohol was observed in younger patients, in EDs in areas with high leisure tourism, on holidays and during the early morning hours. It was also more frequent in individuals intoxicated by amphetamine derivatives (66.2%) and cocaine (65.7%), and was more frequently associated with a reduction in consciousness (odds ratio [OR] = 2.13, 95% confidence interval [CI] 1.69-2.67) and agitation/aggressiveness (OR = 1.22, 95% = 1.04-1.43). A combined adverse event was observed in 114 patients (2.9%) with no differences between individuals co-ingesting or not ethanol (3.1% vs. 2.7%; OR = 1.11, 95% CI = 0.74-1.65).

Conclusion: Co-ingestion of alcohol is more frequent in individuals intoxicated by cocaine and amphetamines and predisposes a greater reduction in the level of consciousness or agitation, although there are no differences in the severity of the episodes of drug intoxication.
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http://dx.doi.org/10.1016/j.ajem.2021.08.046DOI Listing
August 2021

[ENCOVUR-2 study: Analysis of the protocols of action, management and availability of intensive care resources for patients with severe COVID-19 attended in spanish Emergency Departments during the first peak of the pandemic.]

Rev Esp Salud Publica 2021 Aug 11;95. Epub 2021 Aug 11.

Servicio de Urgencias. Hospital Universitario de Canarias. Tenerife. España.

Objective: During the first wave of the COVID-19 pandemic, the availability of a critical care bed was insufficient. The aim of this work was to evaluate the presence of protocols, management in the emergency department (ED) and the availability of intensive care unit (ICU) beds for severe COVID-19 patients attended in Spanish hospital EDs during the first peak of the 2020 pandemic.

Methods: Questionnaire collecting data regarding ED care in March-April 2020 aimed at all Spanish public health care EDs. The respondents were the Chiefs of EDs. The variables of interest were: 1) Presence and of compliance with ED protocols for decision making and adequacy of therapeutic effort; 2) management of COVID-19 patients with non-invasive mechanical ventilation (NIMV) or high flow nasal cannula (HFNC) in the ED; and 3) ICU bed accessibility for ED patients. The results were compared based on the characteristics of the hospital, impact of the pandemic and autonomous community. A descriptive and inferential analysis of the variables studied was performed using the chi-square test and analysis of variance.

Results: A total of 246 questionnaires (89%) were received. Protocols were available in 136 EDs (57.1%). Globally, the protocol was applied in >95% of the EDs, although this was less frequent (76%) in EDs with high impact of the pandemic. 53% of the EDs managed patients with severe COVID-19 with NIMV/HFNC in the ED itself, and 19.4% suffered from lack of ICU beds. The lack of ICU beds for severe COVID-19 patients in the ED significantly differed among periods, and more marked in hospitals with ICU and with high pandemic impact.

Conclusions: It is needed to generalize the implementation of protocols in EDs for the management of severe COVID-19 patients and improve the capacity of the ICUs to homogeneously adjust to the needs.
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August 2021

Socio-Demographic Health Determinants Are Associated with Poor Prognosis in Spanish Patients Hospitalized with COVID-19.

J Gen Intern Med 2021 Jul 8. Epub 2021 Jul 8.

Department of Emergency, Hospital Clínico San Carlos, Calle Profesor Martín-Lagos s/n, 28040, Madrid, Spain.

Introduction: Social vulnerability is a known determinant of health in respiratory diseases. Our aim was to identify whether there are socio-demographic factors among COVID-19 patients hospitalized in Spain and their potential impact on health outcomes during the hospitalization.

Methods: A multicentric retrospective case series study based on administrative databases that included all COVID-19 cases admitted in 19 Spanish hospitals from 1 March to 15 April 2020. Socio-demographic data were collected. Outcomes were critical care admission and in-hospital mortality.

Results: We included 10,110 COVID-19 patients admitted to 18 Spanish hospitals (median age 68 (IQR 54-80) years old; 44.5% female; 14.8% were not born in Spain). Among these, 779 (7.7%) cases were admitted to critical care units and 1678 (16.6%) patients died during the hospitalization. Age, male gender, being immigrant, and low hospital saturation were independently associated with being admitted to an intensive care unit. Age, male gender, being immigrant, percentile of average per capita income, and hospital experience were independently associated with in-hospital mortality.

Conclusions: Social determinants such as residence in low-income areas and being born in Latin American countries were associated with increased odds of being admitted to an intensive care unit and of in-hospital mortality. There was considerable variation in outcomes between different Spanish centers.
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http://dx.doi.org/10.1007/s11606-020-06584-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8266293PMC
July 2021

Cannabinoid hyperemesis syndrome versus cyclic vomiting syndrome.

Adicciones 2021 Jun 15;0(0):1678. Epub 2021 Jun 15.

Departamento de Medicina Física y Farmacología. Universidad de La Laguna, Tenerife.

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http://dx.doi.org/10.20882/adicciones.1678DOI Listing
June 2021

Pulmonary embolism in patients with COVID-19: incidence, risk factors, clinical characteristics, and outcome.

Eur Heart J 2021 08;42(33):3127-3142

Emergency Department, Hospital Clínico San Carlos, IDISSC, UnivesdadComplutenseCalle del Prof Martín Lagos, s/n, 28040 Madrid, Spain.

Aims: We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization.

Methods And Results: We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51-9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65-1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97-2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66-4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations.

Conclusions: PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.
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http://dx.doi.org/10.1093/eurheartj/ehab314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8344714PMC
August 2021

Incidence, risk factors, clinical characteristics and outcomes of deep venous thrombosis in patients with COVID-19 attending the Emergency Department: results of the UMC-19-S8.

Eur J Emerg Med 2021 Jun;28(3):218-226

Emergency Department, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid.

Background And Importance: A higher incidence of venous thromboembolism [both pulmonary embolism and deep vein thrombosis (DVT)] in patients with coronavirus disease 2019 (COVID-19) has been described. But little is known about the true frequency of DVT in patients who attend emergency department (ED) and are diagnosed with COVID-19.

Objective: We investigated the incidence, risk factors, clinical characteristics and outcomes of DVT in patients with COVID-19 attending the ED before hospitalization.

Methods: We retrospectively reviewed all COVID patients diagnosed with DVT in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We compared DVT-COVID-19 patients with COVID-19 without DVT patients (control group). Relative frequencies of DVT were estimated in COVID and non-COVID patients visiting the ED and annual standardized incidences were estimated for both populations. Sixty-three patient characteristics and four outcomes were compared between cases and controls.

Results: We identified 112 DVT in 74 814 patients with COVID-19 attending the ED [1.50‰; 95% confidence interval (CI), 1.23-1.80‰]. This relative frequency was similar than that observed in non-COVID patients [2109/1 388 879; 1.52‰; 95% CI, 1.45-1.69‰; odds ratio (OR) = 0.98 [0.82-1.19]. Standardized incidence of DVT was higher in COVID patients (98,38 versus 42,93/100,000/year; OR, 2.20; 95% CI, 2.03-2.38). In COVID patients, the clinical characteristics associated with a higher risk of presenting DVT were older age and having a history of venous thromboembolism, recent surgery/immobilization and hypertension; chest pain and desaturation at ED arrival and some analytical disturbances were also more frequently seen, d-dimer >5000 ng/mL being the strongest. After adjustment for age and sex, hospitalization, ICU admission and prolonged hospitalization were more frequent in cases than controls, whereas mortality was similar (OR, 1.37; 95% CI, 0.77-2.45).

Conclusions: DVT was an unusual form of COVID presentation in COVID patients but was associated with a worse prognosis.
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http://dx.doi.org/10.1097/MEJ.0000000000000783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082992PMC
June 2021

Incidence, clinical characteristics, risk factors and outcomes of meningoencephalitis in patients with COVID-19.

Eur J Clin Microbiol Infect Dis 2021 Aug 9;40(8):1645-1656. Epub 2021 Mar 9.

Emergency Department, Hospital Clínico San Carlos, IDISSC, Univesidad Complutense, Profesor Martín Lagos s/n, 28040, Marid, Spain.

We investigated the incidence, clinical characteristics, risk factors, and outcome of meningoencephalitis (ME) in patients with COVID-19 attending emergency departments (ED), before hospitalization. We retrospectively reviewed all COVID patients diagnosed with ME in 61 Spanish EDs (20% of Spanish EDs, COVID-ME) during the COVID pandemic. We formed two control groups: non-COVID patients with ME (non-COVID-ME) and COVID patients without ME (COVID-non-ME). Unadjusted comparisons between cases and controls were performed regarding 57 baseline and clinical characteristics and 4 outcomes. Cerebrospinal fluid (CSF) biochemical and serologic findings of COVID-ME and non-COVID-ME were also investigated. We identified 29 ME in 71,904 patients with COVID-19 attending EDs (0.40‰, 95%CI=0.27-0.58). This incidence was higher than that observed in non-COVID patients (150/1,358,134, 0.11‰, 95%CI=0.09-0.13; OR=3.65, 95%CI=2.45-5.44). With respect to non-COVID-ME, COVID-ME more frequently had dyspnea and chest X-ray abnormalities, and neck stiffness was less frequent (OR=0.3, 95%CI=0.1-0.9). In 69.0% of COVID-ME, CSF cells were predominantly lymphocytes, and SARS-CoV-2 antigen was detected by RT-PCR in 1 patient. The clinical characteristics associated with a higher risk of presenting ME in COVID patients were vomiting (OR=3.7, 95%CI=1.4-10.2), headache (OR=24.7, 95%CI=10.2-60.1), and altered mental status (OR=12.9, 95%CI=6.6-25.0). COVID-ME patients had a higher in-hospital mortality than non-COVID-ME patients (OR=2.26; 95%CI=1.04-4.48), and a higher need for hospitalization (OR=8.02; 95%CI=1.19-66.7) and intensive care admission (OR=5.89; 95%CI=3.12-11.14) than COVID-non-ME patients. ME is an unusual form of COVID presentation (<0.5‰ cases), but is more than 4-fold more frequent than in non-COVID patients attending the ED. As the majority of these MEs had lymphocytic predominance and in one patient SARS-CoV-2 antigen was detected in CSF, SARS-CoV-2 could be the cause of most of the cases observed. COVID-ME patients had a higher unadjusted in-hospital mortality than non-COVID-ME patients.
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http://dx.doi.org/10.1007/s10096-021-04206-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939927PMC
August 2021

Recommendations for the early diagnosis of suspected human immunodeficiency virus infection in the emergency department and the referral of patients for follow-up: a consensus statement of the Spanish Society of Emergency Medicine (SEMES).

Emergencias 2020 Dic;32(6):416-426

Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Madrid, España.

Almost half of new diagnoses of human immunodeficiency virus (HIV) infection are made late, leading to increased morbidity and mortality, greater spread of infection, and higher public health care costs. Emergency services care for many patients who share behaviors associated with HIV transmission risk who arrive in clinical situations that are associated with HIV infection. A strategy to increase the rates of early diagnosis by promoting serology for HIV when caring for patients with certain clinical profiles might therefore be the key to improvement. This approach is hardly used at present, however, unless the result of serology would change the management of the acute complaint that led to the visit. These recommendations based on evidence from a search and review of recent publications were developed by a group of experts appointed by the Spanish Society of Emergency Medicine (SEMES). The resulting statement aims to support decision-making by emergency physicians and promote HIV screening and referral to appropriate specialists for follow-up in patients with certain conditions (sexually transmitted infections, herpes zoster, community-acquired pneumonia) or reporting certain scenarios (practice of chemsex, need for post-exposure prophylaxis). These 6 settings were selected because they are often seen in emergency departments and are common in patients with HIV-positive tests. The recommendations address when to order serology for HIV and how to manage the referral process. Included are decision-making tools for emergency physicians.
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December 2020

A case-control emergency department-based analysis of acute pancreatitis in Covid-19: Results of the UMC-19-S.

J Hepatobiliary Pancreat Sci 2020 Dec 1. Epub 2020 Dec 1.

Emergency Department, Hospital Clínico San Carlos, IDISSC, UnivesdadComplutense, Madrid, Spain.

Background/purpose: We investigated the incidence, risk factors, clinical characteristics and outcomes of acute pancreatitis (AP) in patients with COVID-19 attending the emergency department (ED), before hospitalization.

Methods: We retrospectively reviewed all COVID patients diagnosed with AP in 62 Spanish EDs (20% of Spanish EDs, COVID-AP) during the COVID outbreak. We formed two control groups: COVID patients without AP (COVID-non-AP) and non-COVID patients with AP (non-COVID-AP). Unadjusted comparisons between cases and controls were performed regarding 59 baseline and clinical characteristics and four outcomes.

Results: We identified 54 AP in 74 814 patients with COVID-19 attending the ED (frequency = 0.72‰, 95% CI = 0.54-0.94‰). This frequency was lower than in non-COVID patients (2231/1 388 879, 1.61‰, 95% CI = 1.54-1.67; OR = 0.44, 95% CI = 0.34-0.58). Etiology of AP was similar in both groups, being biliary origin in about 50%. Twenty-six clinical characteristics of COVID patients were associated with a higher risk of developing AP: abdominal pain (OR = 59.4, 95% CI = 23.7-149), raised blood amylase (OR = 31.8; 95% CI = 1.60-632) and vomiting (OR = 15.8, 95% CI = 6.69-37.2) being the strongest, and some inflammatory markers (C-reactive protein, procalcitonin, platelets, D-dimer) were more increased. Compared to non-COVID-AP, COVID-AP patients differed in 23 variables; the strongest ones related to COVID symptoms, but less abdominal pain was reported, pancreatic enzymes raise was lower, and severity (estimated by BISAP and SOFA score at ED arrival) was higher. The in-hospital mortality (adjusted for age and sex) of COVID-AP did not differ from COVID-non-AP (OR = 1.12, 95% CI = 0.45-245) but was higher than non-COVID-AP (OR = 2.46, 95% CI = 1.35-4.48).

Conclusions: Acute pancreatitis as presenting form of COVID-19 in the ED is unusual (<1‰ cases). Some clinically distinctive characteristics are present compared to the remaining COVID patients and can help to identify this unusual manifestation. In-hospital mortality of COVID-AP does not differ from COVID-non-AP but is higher than non-COVID-AP, and the higher severity of AP in COVID patients could partially contribute to this increment.
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http://dx.doi.org/10.1002/jhbp.873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753461PMC
December 2020

Incidence, Clinical Characteristics, Risk Factors, and Outcomes of Upper Gastrointestinal Bleeding in Patients With COVID-19: Results of the UMC-19-S12.

J Clin Gastroenterol 2020 Nov 25. Epub 2020 Nov 25.

Emergency Department, Reina Sofia University General Hospital, Murcia.

Objective: The authors investigated the incidence, risk factors, clinical characteristics, and outcomes of upper gastrointestinal bleeding (UGB) in patients with coronavirus disease 2019 (COVID-19), who were attending the emergency department (ED), before hospitalization.

Methods: We retrospectively reviewed all COVID-19 patients diagnosed with UGB in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We formed 2 control groups: COVID-19 patients without UGB (control group A) and non-COVID-19 patients with UGB (control group B). Fifty-three independent variables and 4 outcomes were compared between cases and controls.

Results: We identified 83 UGB in 74,814 patients with COVID-19 who were attending EDs (1.11%, 95% CI=0.88-1.38). This incidence was lower compared with non-COVID-19 patients [2474/1,388,879, 1.78%, 95% confidence interval (CI)=1.71-1.85; odds ratio (OR)=0.62; 95% CI=0.50-0.77]. Clinical characteristics associated with a higher risk of COVID-19 patients presenting with UGB were abdominal pain, vomiting, hematemesis, dyspnea, expectoration, melena, fever, cough, chest pain, and dysgeusia. Compared with non-COVID-19 patients with UGB, COVID-19 patients with UGB more frequently had fever, cough, expectoration, dyspnea, abdominal pain, diarrhea, interstitial lung infiltrates, and ground-glass lung opacities. They underwent fewer endoscopies in the ED (although diagnoses did not differ between cases and control group B) and less endoscopic treatment. After adjustment for age and sex, cases showed a higher in-hospital all-cause mortality than control group B (OR=2.05, 95% CI=1.09-3.86) but not control group A (OR=1.14, 95% CI=0.59-2.19) patients.

Conclusions: The incidence of UGB in COVID-19 patients attending EDs was lower compared with non-COVID-19 patients. Digestive symptoms predominated over respiratory symptoms, and COVID-19 patients with UGB underwent fewer gastroscopies and endoscopic treatments than the general population with UGB. In-hospital mortality in COVID-19 patients with UGB was increased compared with non-COVID patients with UGB, but not compared with the remaining COVID-19 patients.
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http://dx.doi.org/10.1097/MCG.0000000000001465DOI Listing
November 2020

Frequency, Risk Factors, Clinical Characteristics, and Outcomes of Spontaneous Pneumothorax in Patients With Coronavirus Disease 2019: A Case-Control, Emergency Medicine-Based Multicenter Study.

Chest 2021 03 20;159(3):1241-1255. Epub 2020 Nov 20.

Emergency Department, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid, Spain.

Background: Recent reports of patients with coronavirus disease 2019 (COVID-19) developing pneumothorax correspond mainly to case reports describing mechanically ventilated patients. The real incidence, clinical characteristics, and outcome of spontaneous pneumothorax (SP) as a form of COVID-19 presentation remain to be defined.

Research Question: Do the incidence, risk factors, clinical characteristics, and outcomes of SP in patients with COVID-19 attending EDs differ compared with COVID-19 patients without SP and non-COVID-19 patients with SP?

Study Design And Methods: This case-control study retrospectively reviewed all patients with COVID-19 diagnosed with SP (case group) in 61 Spanish EDs (20% of Spanish EDs) and compared them with two control groups: COVID-19 patients without SP and non-COVID-19 patients with SP. The relative frequencies of SP were estimated in COVID-19 and non-COVID-19 patients in the ED, and annual standardized incidences were estimated for both populations. Comparisons between case subjects and control subjects included 52 clinical, analytical, and radiologic characteristics and four outcomes.

Results: We identified 40 occurrences of SP in 71,904 patients with COVID-19 attending EDs (0.56‰; 95% CI, 0.40‰-0.76‰). This relative frequency was higher than that among non-COVID-19 patients (387 of 1,358,134, 0.28‰; 95% CI, 0.26‰-0.32‰; OR, 1.93; 95% CI, 1.41-2.71). The standardized incidence of SP was also higher in patients with COVID-19 (34.2 vs 8.2/100,000/year; OR, 4.19; 95% CI, 3.64-4.81). Compared with COVID-19 patients without SP, COVID-19 patients developing SP more frequently had dyspnea and chest pain, low pulse oximetry readings, tachypnea, and increased leukocyte count. Compared with non-COVID-19 patients with SP, case subjects differed in 19 clinical variables, the most prominent being a higher frequency of dysgeusia/anosmia, headache, diarrhea, fever, and lymphopenia (all with OR > 10). All the outcomes measured, including in-hospital death, were worse in case subjects than in both control groups.

Interpretation: SP as a form of COVID-19 presentation at the ED is unusual (< 1‰ cases) but is more frequent than in the non-COVID-19 population and could be associated with worse outcomes than SP in non-COVID-19 patients and COVID-19 patients without SP.
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http://dx.doi.org/10.1016/j.chest.2020.11.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678420PMC
March 2021

Impact of the COVID-19 pandemic on hospital emergency departments: results of a survey of departments in 2020 - the Spanish ENCOVUR study.

Emergencias 2020 09;32(5):320-331

Servicio de Urgencias, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Barcelona, España.

Objectives: To estimate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the organization of Spanish hospital emergency departments (EDs). To explore differences between Spanish autonomous communities or according to hospital size and disease incidence in the area.

Material And Methods: Survey of the heads of 283 EDs in hospitals belonging to or affiliated with Spain's public health service. Respondents evaluated the pandemic's impact on organization, resources, and staff absence from work in March and April 2020. Assessments were for 15-day periods. Results were analyzed overall and by autonomous community, hospital size, and local population incidence rates.

Results: A total of 246 (87%) responses were received. The majority of the EDs organized a triage system, first aid, and observation wards; areas specifically for patients suspected of having COVID-19 were newly set apart. The nursing staff was increased in 83% of the EDs (with no subgroup differences), and 59% increased the number of physicians (especially in large hospitals and locations where the COVID-19 incidence was high). Diagnostic tests for the severe acute respiratory syndrome coronavirus 2 were the resource the EDs missed most: 55% reported that tests were scarce often or very often. Other resources reported to be scarce were FPP2 and FPP3 masks (38% of the EDs), waterproof protective gowns (34%), and space (32%). More than 5% of the physicians, nurses, or other emergency staff were on sick leave 20%, 19%, and 16% of the time. These deficiencies were greatest during the last half of March, except for tests, which were most scarce in the first 15 days. Large hospital EDs less often reported that diagnostic tests were unavailable. In areas where the COVID-19 incidence was higher, the EDs reported higher rates of staff on sick leave. Resource scarcity differed markedly by autonomous community and was not always associated with the incidence of COVID-19 in the population.

Conclusion: The COVID-19 pandemic led to organizational changes in EDs. Certain resources became scarce, and marked differences between autonomous communities were detected.
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September 2020

Frequency of five unusual presentations in patients with COVID-19: results of the UMC-19-S.

Epidemiol Infect 2020 08 26;148:e189. Epub 2020 Aug 26.

Emergency Department, Hospital Clínico San Carlos, IDISSC, Univesdad Complutense, Madrid, Spain.

Despite SARS-CoV-19 infection has a stereotypical clinical picture, isolated cases with unusual manifestations have been reported, some of them being well-known to be triggered by viral infections. However, the real frequency in COVID-19 is unknown. Analysing data of 63 822 COVID patients attending 50 Spanish emergency department (ED) during the COVID outbreak, before hospitalisation, we report frequencies of (myo)pericarditis (0.71‰), meningoencephalitis (0.25‰), Guillain-Barré syndrome (0.13‰), acute pancreatitis (0.71‰) and spontaneous pneumothorax (0.57‰). Compared with general ED population, COVID patients developed more frequently Guillain-Barré syndrome (odds ratio (OR) 4.55, 95% confidence interval (CI) 2.09-9.90), spontaneous pneumothorax (OR 1.98, 95% CI 1.40-2.79) and (myo)pericarditis (OR 1.45, 95% CI 1.07-1.97), but less frequently pancreatitis (OR 0.44, 95% CI 0.33-0.60).
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http://dx.doi.org/10.1017/S0950268820001910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477462PMC
August 2020

Analysis of clinical characteristics and outcomes in patients with COVID-19 based on a series of 1000 patients treated in Spanish emergency departments.

Emergencias 2020 Ago;32(4):233-241

Servicio de Urgencias, Hospital General Universitario de Alicante, Universidad Miguel Hernández, Elche, Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), España.

Objectives: To describe the clinical characteristics of patients with coronavirus disease 2019 (COVID-19) treated in hospital emergency departments (EDs) in Spain, and to assess associations between characteristics and outcomes.

Material And Methods: Prospective, multicenter, nested-cohort study. Sixty-one EDs included a random sample of all patients diagnosed with COVID-19 between March 1 and April 30, 2020. Demographic and baseline health information, including concomitant conditions; clinical characteristics related to the ED visit and complementary test results; and treatments were recorded throughout the episode in the ED. We calculated crude and adjusted odds ratios for risk of in-hospital death and a composite outcome consisting of the following events: intensive care unit admission, orotracheal intubation or mechanical ventilation, or in-hospital death. The logistic regression models were constructed with 3 groups of independent variables: the demographic and baseline health characteristics, clinical characteristics and complementary test results related to the ED episode, and treatments.

Results: The mean (SD) age of patients was 62 (18) years. Most had high- or low-grade fever, dry cough, dyspnea, and diarrhea. The most common concomitant conditions were cardiovascular diseases, followed by respiratory diseases and cancer. Baseline patient characteristics that showed a direct and independent association with worse outcome (death and the composite outcome) were age and obesity. Clinical variables directly associated with worse outcomes were impaired consciousness and pulmonary crackles; headache was inversely associated with worse outcomes. Complementary test findings that were directly associated with outcomes were bilateral lung infiltrates, lymphopenia, a high platelet count, a D-dimer concentration over 500 mg/dL, and a lactate-dehydrogenase concentration over 250 IU/L in blood.

Conclusion: This profile of the clinical characteristics and comorbidity of patients with COVID-19 treated in EDs helps us predict outcomes and identify cases at risk of exacerbation. The information can facilitate preventive measures and improve outcomes.
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July 2020

Personal protection against COVID-19 in the emergency department: neither heroes nor cowards.

Emergencias 2020 Ago;32(4):223-224

Servicio de Microbiología y control de la infección. Hospital Universitario de Canarias, La Laguna, Tenerife, España.

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July 2020

Myocarditis associated with the use of energy drinks: a case report.

Emergencias 2020 06;32(3):217-218

Servicio de Cardiología, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, España. Facultad de Ciencias de la Salud, Universidad Europea de Canarias, La Orotava, Santa Cruz de Tenerife, España.

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June 2020

[Acute poisoning by chemical products: analysis of the first 15 years of the Spanish Toxic Surveillance System (SETv)].

Rev Esp Salud Publica 2020 01 16;94. Epub 2020 Jan 16.

Servicio de Urgencias. Hospital Universitario de Canarias. Tenerife. España.

Objective: There are few epidemiological studies on acute poisonings from pesticides, industrials and household products in Spain. The objective of this work is to describe the epidemiological and clinical profile of acute poisonings by chemical products in our country, and analyze their annual evolution.

Methods: The Spanish Toxicovigilance System (SETv) is a prospective registry that includes 32 Emergency Departments and Intensive Care Units in Spain. An observational descriptive study of acute poisoning by chemical agents (excluding pharmacological products and illicit drugs) was carried out, within 1999-2014. Statistical analysis was performed using Chi-square or exact Fisher's tests. Non-parametric continuous variables were compared using the Mann-Whitney U test. P-value less than 0.05 were considered significant.

Results: The 10,548 cases studied had a mean age of 38.41 (±22.07) years, being significantly higher in women (p=0.0001). 67.7% of the poisonings occurred at home, and the most frequent routes of exposure were respiratory (48.3%), digestive (35.3%) and ocular (13.1%). The most frequent toxic groups were toxic gases (31%), caustics (25.6%) and irritant gases (12.1%). Of the patients that required treatment (76.2%), antidotes were used in 27.2%. 20.6% of the patients were admitted at Hospital, with a median stay of 32 (±151.94) days, with significant differences for pesticides and solvents (p=0.02). Sequelae were presented at discharge in 2.1% of patients. Mortality was 1.4% (146 patients) with a mean age of 62.08 years (±19.58) (p=0.0001).

Conclusions: The reduction of chemical poisonings should be prevented in the domestic environment, taking into account the sources of exposure to carbon monoxide and the handling of household cleaning products, both caustic liquids and the generation of irritating gases when mixed.
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January 2020

Impact of exposure of emergency patients with acute heart failure to atmospheric Saharan desert dust.

Emergencias 2019 Jun;31(3):161-166

Facultad de Ciencias de La Salud, Universidad Europea de Canarias, Tenerife, España. Servicio de Urgencias, Hospital Universitario de Canarias, Tenerife, España.

Objectives: To explore whether episodes of exposure to atmospheric Saharan dust is a risk factor for hospitalization in patients with acute heart failure (AHF) attended in a hospital emergency department (ED).

Methods: Single-center retrospective study of patients with AHF. The cohort was analyzed in 2 groups: ED patients hospitalized with AHF and patients discharged home from the ED. Air pollution on the 5 days leading to ED admission for AHF was recorded as the average concentration of breathable particulate matter with an aerodynamic diameter of no more than 10 µm (PM10) in the following ranges: fine PM (diameter less than 2.5 µm) or coarse PM (diameters between 2.5 and 10 µm). High Saharan dust pollution exposure was defined by mean daily PM10 concentrations between 50 and 200 µg/m3. Multivariable analysis was used to estimate risk for AHF in relation to PM10 exposure in the 5 days before the ED visit.

Results: A total of 1097 patients with AHF were treated in the ED; 318 of them (29%) were hospitalized and 779 (71%) were discharged home. Hospitalized patients were older, had more concomitant illnesses, and more episodes of exposure to Saharan dust (P < .0001). Multivariable analysis confirmed the association between Saharan dust exposure and hospital admission in these patients (odds ratio, 2.36; 95% CI, 1.21-4.58; P = .01).

Conclusion: In the absence of prospective studies, the results of this series suggest that exposure to high levels of Saharan dust (PM10 concentrations between 50 and 200 µg/m3) may be a precipitating factor for hospitalization in AHF episodes.
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June 2019

Improving the diagnosis of cannabinoid hyperemesis syndrome.

Rev Esp Enferm Dig 2019 07;111(7):574-575

Servicio de Urgencias, Hospital Universitario de Canarias.

Two recent publications in this journal regarding cannabinoid hyperemesis syndrome (CHS) reflect a common fact in the clinical practice. Although the syndrome is increasingly well-known, patients still receive a late diagnosis, sometimes after years of delay. This entails multiple visits to the ER, as well multiple outpatient visits and diagnostic tests in gastroenterology departments. Furthermore, there are many unnecessary hospital admissions that are often accompanied by an uncertain discharge diagnosis (psychogenic vomiting, etc.).
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http://dx.doi.org/10.17235/reed.2019.6003/2018DOI Listing
July 2019

Emergency departments as observatories: a good view of street use and its clinical consequences.

Emergencias 2018 Dic;30(6):377-379

Centro de Salud Orotava-Dehesas. Servicio Canario de la Salud, Tenerife, España. Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Tenerife, España.

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July 2019

Assessment of 22 inorganic elements in human amniotic fluid: a cross-sectional study conducted in Canary Islands (Spain).

Int J Environ Health Res 2019 Apr 6;29(2):130-139. Epub 2018 Sep 6.

c Emergency Service , Hospital Universitario de Canarias , La Laguna, Tenerife , España.

We conducted a cross-sectional study in the Hospital Universitario de Canarias (Tenerife, Canary Islands, Spain) measuring 22 inorganic elements in amniotic fluid (AF) samples obtained from 65 pregnant women. ICP-MS was used for quantification of inorganic elements. Newborn parameters at delivery were all within the normal range. Concentrations of all elements were detected in measurable amounts in AF. The concentration of elements was similar to those reported in the literature. The concentrations of the most dangerous heavy metals - Cd, Cr, Ni, Hg and Pb - were lower than those reported by other authors. This study demonstrates that toxic inorganic elements pass into and accumulate in AF. The presence of such pollutants in contact with developing embryos from the intrauterine period could exert adverse health effects that deserve future investigations.
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http://dx.doi.org/10.1080/09603123.2018.1516284DOI Listing
April 2019

Validation of an uncertainty of illness scale adapted to use with Spanish emergency department patients and their accompanying relatives or friends.

Emergencias 2018 Abr;30(2):105-114

Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Tenerife, España. Servicio de Urgencias, Hospital Universitario de Canarias, La Laguna, Tenerife, España.

Objectives: To validate a Spanish adaptation of the Mishel Uncertainty of Illness Scale for use with emergency-department (ED) patients and their accompanying relatives or friends (the UIS-ED).

Material And Methods: We first developed a version of the questionnaire for Spanish ED situations. Next we assessed the content validity index for each of its items, revised it, and reassessed its face validity to produce a second version, which we then piloted in 20 hospital ED patients. A third revised version was then validated in a population of 320 adults (160 patients and 160 accompanying persons) who attended the ED between November 2015 and September 2016. The 12-item UIS-ED (60 points) was administered by 2 nurses while the patients and accompanying persons were in the ED. We gathered sociodemographic and clinical data as well as the subjects' perception about the information they were given.

Results: The mean (SD) uncertainty score among patients was 29 (11) points. Accompanying persons had a mean score of 36 (13) points. Factorial analysis confirmed the instrument's construct validity, finding that both dimensions of the original Mishel scale (complexity and ambiguity) were present in 6 items each. Factorial analysis explained 60% of the total variance in the patient version and 67% of the variance in the version for accompanying persons. Reliability statistics were good, with Cronbach's α values ranging from 0.912 to 0.938. Split-half reliability statistics ranged from 0.901 to 0.933. Correlations were significant in the analysis of convergent validity.

Conclusion: The UIS-ED questionnaire may prove to be a simple, valid, and reliable way for assessing uncertainty in patients and their accompanying friends or relatives attending Spanish EDs.
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May 2019

[Scientific publication output of Spanish emergency physicians from 2005 to 2014: a comparative study].

Emergencias 2017 10;29(5):327-334

Grupo de Investigación "Urgencias: procesos y patologías", IDIBAPS, Barcelona, España. Área de Urgencias, Hospital Clínic, Barcelona; Universitat de Barcelona, España.

Objectives: To analyze the research output of Spanish emergency physicians between 2005 and 2014 and to compare it to their output in the previous 10-year period (1995-2004) as well as to that of emergency physicians in other countries and Spanish physicians in other specialties.

Material And Methods: Original articles indexed in the Science Citation Index Expanded of the Web of Science were included. Documents from Spanish emergency physicians were identified by combining the word Spain and any other search term identifying an emergency service or unit in Spain. To identify articles from 7 other Spanish specialties (hematology, endocrinology, cardiology, pneumology, digestive medicine, pediatrics, surgery and orthopedic medicine or traumatology) and emergency physicians in 8 other countries (United States, United Kingdom, Ireland, Italy, France, Germany, Netherlands, Belgium) we used similar strategies. Information about production between 1995 and 2004 was extracted from a prior publication.

Results: Spanish emergency physicians signed 1254 articles (mean [SD], 125 [44] articles/y) between 2005 and 2014. That level of productivity was greater than in the 1995-2004 period (mean, 26 [14] articles/y), although the annual growth rate fell from 12.5% in the previous 10-year period to 5.2% in the most recent one. Emergency medicine was among the least productive Spanish specialties we studied, but our discipline's annual growth rate of 5.2% was the highest. Spanish emergency medicine occupies an intermediate position (ranking fifth) among the 9 countries studied, although the population-adjusted rank was higher (fourth). When output was adjusted for gross domestic product, Spain climbed higher in rank, to second position. The annual growth rate was the fourth highest among countries, after Germany (9.9%), the Netherlands (7.3%), and Italy (6.0%).

Conclusion: The research output of Spanish emergency physicians continues to be quantitatively lower than that of other Spanish specialties and of emergency physicians in other countries. The annual rate of growth in publications, although good, fell below the growth rate of the previous period.
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October 2017

Analysis of the citation of articles published in the European Journal of Emergency Medicine since its foundation.

Eur J Emerg Med 2019 Feb;26(1):65-70

Department of emergency, Hospital Clínic, Barcelona, Research Group "Emergencies: Processes and Pathologies", IDIBAPS, University of Barcelona, Spain.

Objectives: The aim of this study was to evaluate the evolution of the citation of articles from the European Journal of Emergency Medicine (EJEM) from 1994 (EJEM foundation) to 2015 and identify highly cited articles and their principal characteristics and determine a possible correlation between the citations counted in different databases.

Materials And Methods: We obtained the articles published in EJEM from 1994 to 2015 in ISI-WoS (main source) and Scopus, Google Scholar, and Medline databases (accessory sources). The citations were quantified and their annual evolution and the bibliometric indices derived (impact factor and SCImago Journal Rank) were evaluated. We identified and analyzed the highly cited EJEM articles and evaluated the possible correlation between the citations counted for these articles in the databases.

Results: Overall, 1705 EJEM articles were cited 9422 times in 8122 different articles. The evolution of the global citation, impact factor, and SCImago Journal Rank from 1994 to 2015 increased significantly. The h-index of EJEM was 30, and 31 articles were considered highly cited (≥30 citations), 16.1% of them being clinical trials. By subjects, 22.5% corresponded to cardiology, 19.3% to emergency department management, and 12.9% to pediatrics; by countries, 81% were from Europe, with Belgian authors publishing four (12.9%) highly cited articles, and French, Spanish, British, and Swedish authors having three (9.7%) each. Two studies in the EJEM achieved the definition of 'citation classics' (more than 100 citations). The number of citations in all the databases, except Medline, showed statistically significant correlations.

Conclusion: Citation of EJEM articles has progressively increased and EJEM bibliometric indicators have improved; most highly cited articles are mainly by European authors.
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http://dx.doi.org/10.1097/MEJ.0000000000000502DOI Listing
February 2019

Cannabinoid hyperemesis syndrome: potential mechanisms for the benefit of capsaicin and hot water hydrotherapy in treatment.

Clin Toxicol (Phila) 2018 Jan 21;56(1):15-24. Epub 2017 Jul 21.

c Área de Toxicología Clínica, Servicio de Urgencias, Universidad Europea de Canarias , Tenerife , Spain.

Introduction: Cannabinoid hyperemesis syndrome is a clinical disorder that has become more prevalent with increasing use of cannabis and synthetic cannabinoids, and which is difficult to treat. Standard antiemetics commonly fail to alleviate the severe nausea and vomiting characteristic of the syndrome. Curiously, cannabinoid hyperemesis syndrome patients often report dramatic relief of symptoms with hot showers and baths, and topical capsaicin.

Objectives: In this review, we detail the pharmacokinetics and pharmacodynamics of capsaicin and explore possible mechanisms for its beneficial effect, including activation of transient receptor potential vanilloid 1 and neurohumoral regulation. Putative mechanisms responsible for the benefit of hot water hydrotherapy are also investigated.

Methods: An extensive search of PubMed, OpenGrey, and Google Scholar from inception to April 2017 was performed to identify known and theoretical thermoregulatory mechanisms associated with the endocannabinoid system. The searches resulted in 2417 articles. These articles were screened for relevant mechanisms behind capsaicin and heat activation having potential antiemetic effects. References from the selected articles were also hand-searched. A total of 137 articles were considered relevant and included. Capsaicin: Topical capsaicin is primarily used for treatment of neuropathic pain, but it has also been used successfully in some 20 cases of cannabinoid hyperemesis syndrome. The pharmacokinetics and pharmacodynamics of capsaicin as a transient receptor potential vanilloid 1 agonist may explain this effect. Topical capsaicin has a longer half-life than oral administration, thus its potential duration of benefit is longer. Capsaicin and transient receptor potential vanilloid 1: Topical capsaicin binds and activates the transient receptor potential vanilloid 1 receptor, triggering influx of calcium and sodium, as well as release of inflammatory neuropeptides leading to transient burning, stinging, and itching. This elicits a novel type of desensitization analgesia. Transient receptor potential vanilloid 1 receptors also respond to noxious stimuli, such as heat (>43 °C), acids (pH <6), pain, change in osmolarity, and endovanilloids. The action of topical capsaicin may mimic the effect of heat-activation of transient receptor potential vanilloid 1. Endocannabinoid system and transient receptor potential vanilloid 1: Cannabinoid hyperemesis syndrome may result from a derangement in the endocannabinoid system secondary to chronic exogenous stimulation. The relief of cannabinoid hyperemesis syndrome symptoms from heat and use of transient receptor potential vanilloid 1 agonists suggests a complex interrelation between the endocannabinoid system and transient receptor potential vanilloid 1. Temperature regulation: Hot water hydrotherapy is a mainstay of self-treatment for cannabinoid hyperemesis syndrome patients. This may be explained by heat-induced transient receptor potential vanilloid 1 activation. "Sensocrine" antiemetic effects: Transient receptor potential vanilloid 1 activation by heat or capsaicin results in modulation of tachykinins, somatostatin, pituitary adenylate-cyclase activating polypeptide, and calcitonin gene-related peptide as well as histaminergic, cholinergic, and serotonergic transmission. These downstream effects represent further possible explanations for transient receptor potential vanilloid 1-associated antiemesis.

Conclusions: These complex interactions between the endocannabinoid systems and transient receptor potential vanilloid 1, in the setting of cannabinoid receptor desensitization, may yield important clues into the pathophysiology and treatment of cannabinoid hyperemesis syndrome. This knowledge can provide clinicians caring for these patients with additional treatment options that may reduce length of stay, avoid unnecessary imaging and laboratory testing, and decrease the use of potentially harmful medications such as opioids.
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http://dx.doi.org/10.1080/15563650.2017.1349910DOI Listing
January 2018

Use of Capsaicin Cream in Cannabis Hyperemesis Syndrome.

J Emerg Med 2017 05 6;52(5):760. Epub 2017 Mar 6.

Hospital General de Alicante, Alicante, Spain.

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http://dx.doi.org/10.1016/j.jemermed.2016.10.050DOI Listing
May 2017

Study Design and Rationale of "A Multicenter, Open-Labeled, Randomized Controlled Trial Comparing MIdazolam Versus MOrphine in Acute Pulmonary Edema": MIMO Trial.

Cardiovasc Drugs Ther 2017 Apr;31(2):209-213

Departamento de Ciencias Médicas Básicas (Unidad de Fisiología), Universidad de La Laguna, Santa Cruz de Tenerife, Spain.

Purpose: Morphine has been used for several decades in cases of acute pulmonary edema (APE) due to the anxiolytic and vasodilatory properties of the drug. The non-specific depression of the central nervous system is probably the most significant factor for the changes in hemodynamics in APE. Retrospective studies have shown both negative and neutral effects in patients with APE and therefore some authors have suggested benzodiazepines as an alternative treatment. The use of intravenous morphine in the treatment of APE remains controversial.

Methods: The MIdazolan versus MOrphine in APE trial (MIMO) is a multicenter, prospective, open-label, randomized study designed to evaluate the efficacy and safety of morphine in patients with APE. The MIMO trial will evaluate as a primary endpoint whether intravenous morphine administration improves clinical outcomes defined as in-hospital mortality. Secondary endpoint evaluation will be mechanical ventilation, cardiopulmonary resuscitation, intensive care unit admission rate, intensive care unit length of stay, and hospitalization length.

Conclusions: In the emergency department, morphine is still used for APE in spite of poor scientific background data. The data from the MIMO trial will establish the effect-and especially the risk-when using morphine for APE.
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http://dx.doi.org/10.1007/s10557-017-6722-5DOI Listing
April 2017

Cocaine users and cutaneous and mucosal manifestations.

Med Clin (Barc) 2017 01 27;148(1):e1. Epub 2016 Oct 27.

Área de Toxicología Clínica, Servicio de Urgencias, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España; Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Santa Cruz de Tenerife, España.

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http://dx.doi.org/10.1016/j.medcli.2016.09.023DOI Listing
January 2017

Perspectives in the treatment for cannabinoid hyperemesis syndrome.

Adicciones 2017 Jan 12;29(2):134-135. Epub 2017 Jan 12.

Hospital Universitario de Canarias. Universidad Europea de Canarias..

Letter to the editor.
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http://dx.doi.org/10.20882/adicciones.875DOI Listing
January 2017
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