Objective: RDW is a measure of the variation of red blood cell width, reported as part of standard complete blood count; many paper reported results about the role of RDW in heart failure; the role of RDW in Acute Coronary Syndromes (ACS) is less known.Methods: We enrolled 173 consecutive patients, admitted to the coronary care unit of our hospital, with a diagnosis of obstructive ACS, documented by the evidence of obstructive coronary lesions on coronary angiography.We divided patients into two Groups: Group 1, with normal values of RDW; Group 2, with RDW values higher than normal range.Ventricular systolic function, was measured with echocardiography.Results: Patients of group 1 had a greater Ejection Fraction (p=0.03) and lower values of NT-proBNP (p=0.001).Finally we found a lower eGFR in patients of group 2, than in patients of group 1 (p=0.0001).Conclusions: Our results suggest that RDW is a routine and inexpensive test that can provide information concerning severity of clinical condition in acute phase of an ACS, both as regards the cardiac contractility, both with regard to renal function.These variables are important prognostic factors in patients after ACS.
Standardized microbiological methods used in clinical analysis are based on traditional microbial enrichment on selective media, possibly followed by characterization of bacteria with molecular methods. These techniques present several difficulties, such as the subjectivity in the interpretation of genetic, biochemical or morphological tests and the possible interference of biological matrices, specially when low levels of contamination are present. In addition, standard- ized microbiological analyses are characterised by the high cost of the method, both in terms of labor and supplies, and above all, by the long time needed to obtain definitive results (from 3 to 7 days). These reasons have led to the develop- ment and refinement of microbiological POCTs which are now available for several microorganisms, even thought no mi- crobiological POCT was up to now developed for the count of total viable bacteria (TVC) in serum, urine or other bio- logical fluids. MBS srl (a spin-off of Roma Tre University, Rome, Italy) has developed and patented an alternative method for selective counting of bacteria, called Micro Biological Survey (MBS) method. The MBS method is based on colorimetric survey performed in mono-use disposable reaction vials in which samples can be inoculated without any preliminary treatment. The analyses can be carried out by untrained personnel and anywhere they are necessary, without the need for any other instrumentation than a thermostated optical reader that can automatically detect the colour change providing the number of bacteria present into the sample. The MBS method measures the catalytic activity of redox enzymes in the main meta- bolic pathways of bacteria, allowing an unequivocal correlation between the observed enzymatic activity and the number of viable cells present in the samples. The time required for a color change is inversely related to the log of bacterial con- centration; like an enzymatic reaction, the greater the number of bacteria, the faster the color change. The objective of this study was the primary validation, in accord with ISO 13843:2003 (Guidance on validation of micro- biological methods), of the quantitative Micro Biological Survey (MBS) method for Total Viable Count (TVC). Valida- tion aims to compare the results obtained with an alternative method, in this case the MBS method, with the results ob- tained with the reference method. To verify the equivalence between the two methods different parameters were analyzed: selectivity, linearity and accuracy. The validation has shown that the MBS method gives similar results and is in agree- ment with the reference methods. The MBS method could therefore represent a worthy aid in microbiological analysis as POCT device without replacing the analysis carried out with traditional methods which are very precise though often long and complex.
Non-operative management (NOM) is considered the gold standard treatment for blunt liver trauma in hemodynamically stable patients since it is both feasible and safe. The reported rate of NOM ranged from 82 to 100% according to different series. The feasibility of NOM is lower in patients with severe liver injury. Since NOM has reduced mortality rates, the focus now has shifted to lowering hepatic morbidity, which is reported to be significant, from 10 to 25%. There are four types of complications after NOM: abdominal compartment syndrome, bleeding, Infectious complications and biliary complications. When present, complications of complex blunt hepatic injuries are difficult to treat, the hospital stay is longer and the ICU mortality is higher. 85% of these complications can be safely managed non-operatively. A strict clinical follow-up and keeping in mind every possible complication let clinicians diagnose and treat quickly.
Background: Although pain is the most common complaint in the Emergency Department (ED), there is still a lack of adequate pain treatment by Emergency Physicians.Aim of this study was to describe pain management in ED from triage to discharge and to verify the effect of pain treatment in ED on a short term follow-up after discharge in order to evaluate patient's outcome.Methods: A prospective multicentric study was conducted over two consecutive one week period in 4 ED teaching hospitals in Italy.All patients presenting with an acute, painful condition were eligible to participate in the study.The complete ED pain treatment was recorded, we enrolled 582 consecutive patients.One week after ED discharge a follow up evaluation through a phone call on patient's pain clinical condition was also obtained.Results: There was a statistical significant difference between nurse and Emergency Physicians pain judgement (p<0.001).During ED visit: 54.2% received non steroid anti inflammatory drug (NSAID), 12.2% received paracetamol and 9.9% tramadol while morphine was used only in 5.6%of patients.Overall patient's satisfaction at one-week follow-up was as follows: in 63% of patients pain was completely absent, but on the other hand, 37% of patients had no pain relief, despite analgesic therapy prescription. Conclusion:In our study we found differences between nurses and physicians judgments, they disagreed on the severity of pain.It was observed a low use of pain intensity scale with a formal measurement scales to assess pain.Our study demonstrates the importance of adequate ED and analgesic drug prescription for patients referring for pain in ED, and follow up assessment, many patients in follow up reported continued pain because of poor prescription of analgesic drug at discharge from ED. Improving analgesia in ED seems to be crucial for patients' quality of life and for preventing ED readmission for relapse of pain.
Background: antibiotic therapy and prophylaxis of epidermal wounds in emergency room are often made empirically in case of clinics due to infective complications, although there are no scientific evidences supporting their validity yet.Furthermore, resistance to many antibiotics is a constantly growing problem, especially in Lombardy, Italy.When needed, better prefer beta-lactams or macrolides for their large-spectrum activity. Methods:We identified all patients (pts) treated to our emergency room for epidermal wounds in a period between 1st and 31st july 2012.Then, we performed a retrospective, observational analysis of epidemiological, clinical and therapeutic features of those pts.<12 years old individuals were exluded.We considered at high risk of infections pts with at least one of the following comorbidities: diabetes, neoplastic disease, therapy with corticosteroids, immunodepression.Results: A total of 201 pts were evaluated, 143 males (71.1%) and 58 females (28.9%).The median age was 46,3 yrs.Among the pts 101 (50.2%) needed treatment with suture.13 (6.5%)pts came after at least 12 hrs after the accident.107 (53,2%) pts did not need therapy, while in 82 (40.8%) cases antibiotic prophylaxis (89% beta-lactams, 9.8% macrolides, 1.2% others) has been prescribed; 4 (2%) were adviced to start antibiotic therapy only in case of acute epidermal infection development at home; we don't have this information about 8 pts (4%).In 185 (93.5%) pts clinical signs of acute epidermal infection were missing.15 (7.5%) pts had an high risk of developing infections in history taking; 3 of them received antibiotic prophylaxis, 8 didn't, 4 not known.In 143 individuals (71,1%) the history taking has been insufficient. Conclusions:Even if acute local infection is possible in wounded pts, only subjects at high risk should be closely screened and monitored to detect early infection, in order to evaluate the necessity of specific antibiotic therapy.Clinical evaluation should also include comorbilities as valvulopathy or immunosuppression.
Background: Pulmonary Embolism (PE) is a disease characterized by not specific signs and symptoms.In Italy, there are about 65,000 cases per year; mortality is about 30% if PE is not identified and decreases to 2-8% if PE is recognized and treated.International guidelines include several strategies for diagnosing the disease with confidence.The diagnostic pathway includes a clinical approach with the Wells and Revised Geneva scores, the use of D-dimer and, eventually, a Computed Tomography (CT).The CT seems to be the ideal investigation to confirm or exclude PE but it is not free from complications.Sometimes in medical practice clinicians tend to order CT more frequently than necessary, reflecting a defensive behavior instead of an evidence based behavior.This practice exposes patients to some risks, especially for kidney.Objective: To identify the efficiency of the use of clinical scores and diagnostic algorithms following the latest guidelines in patients with suspicion of PE.To analyze how many CTs could be avoided using the right approach and to evaluate the importance of any clinical variable.Eventually, to apply the two scores together (Wells score and Revised Geneva score). Methods and Materials:A retrospective, single centre, cohort study was performed from January 2011 to April 2012.All patients who made a CT in the Emergency Room for suspicion of PE were collected and classified in two groups: PEand PE +.In all patients Wells Score and Revised Geneva Score were calculated.Results: 111 patients (64% female; mean age 72±16 years) were studied.There were no differences in anamnestic, clinical and laboratory variables between the two groups.With the classic pathway 6 patients could have been safely ruled out without performing a CT.With the Wells score one PE+ patient had a low pre-test probability; with the Revised Geneva score actually 7 PE+ patients had a low pre-test probability.These results were source of doubt about the reliability of the scores.So we tried to use the two scores together, and we achieved these results: in 7 patients PE could have been safely excluded without even using CT scan. Conclusions:The study focuses on the clinical approach to PE.The clinical scores proposed by guidelines (Wells score and Revised Geneva score) are unreliable if used alone, out of a pathway.We propose to the application of the two score together to exclude PE safely without performing CT when not necessary.
Objectives: The aim of this study was to assess the retention rate of Advanced Cardiac Life Support (ACLS) skills in third-year medical students who had few clinical opportunities or responsibilities to use them. It was hypothesised that using high-fidelity simulation would increase skills retention. Methods: This was a prospective observational study of 120 rising third year medical students. All students took and eventually passed a full two-day ACLS provider course. Subsequently, during the end of the year Comprehensive Clinical Performance Examination (CCPX) all students participated in a mega code with a Laerdal Hi-Fidelity Simulator. Their performance in 25 critical actions was dichotomously rated as "successful" or "not successful." Results: All students passed the initial ACLS course, six required standard remediation. One hundred and sixteen students took the end of year CCPX exam, and a success rate for critical actions ranged between 3.4% and 100%. Most students did well at recognition of fatal arrhythmias and cardiopulmonary resuscitation (CPR). Students performed poorly in airway/breathing assessment and management, as well as management of arrhythmias. Conclusions: ACLS skills are an important skill set for up coming physicians, and unless they are used in practice, they deteriote very quickly. Simulation did not increase student retention rates of ACLS skills to a great extent. Students did well in identifying problems, but did not treat these appropriately. This study suggests that educators should examine the goals of teaching ACLS to providers who have not clearly defined role in resuscitation.
Background: Communication of emergency department (ED) visit information to general practitioners (GP) is often inadequate and can negatively impact on patient care. Further, the use of email as a communication tool between GP and ED providers has been not been well explored. Objectives: We sought to assess the desirability, feasibility and ideal functionalities of a novel web-based, automated post- ED visit communication tool for GPs. Methods: A cross-sectional needs assessment survey was conducted among the top 300 referring GPs to a single ED in Toronto, Canada. The main outcome measures were: current GP awareness of patient ED visits and anticipated uptake of an electronic notification and health record communication tool. Results: One hundred ninety-eight physicians responded (66% response rate). Fifty-eight percent of GPs were unaware or only sometimes aware of patients' ED visits. Nearly all (94%) would welcome an automated electronic system to com- municate post-ED discharge health information in real-time. Two-thirds (67%) were in favour of their patients having on- line access to their own health records. Physicians less than 50 years of age were more likely than those greater than 50 to use both an office computer with internet and email access (96% versus 69%)and an electronic medical record (EMR;57% versus 41%). Conclusions: This needs assessment survey highlights an unmet need for improved ED-GP health record communication and suggests that GP uptake of a novel web-based post-ED visit notification and health record transfer system would be high.
Background: SIRS/sepsis accounts for vast majority of deaths in ICU a medical ward department.More than 650,000 cases of sepsis are diagnosed in the United States annually, with 30-50% mortality and individually cost more than 22,000 dollars.Biomarkers could be useful tools for early risk stratification in these patients.Angiopioietin-2 (Ang-2) is a proinflammatory mediator of endothelial injury, which has received considerable attention over the past decade but little is known about its correlation with organ failure and mortality in SIRS/sepsis admitted to a medical ward.Methods: Ang-2 plasma levels, Charlson index, SOFA and routine laboratory test were carried out in 80 SIRS patients admitted to medical ward within 4 hours from diagnosis.Survival and organ dysfunction in the following week were recorded.Investigators were blinded from Ang-2 results.Results: Ang-2 plasma levels were higher in patients suffering from renal, pulmonary and hemostatic dysfunction (16, 6, 4% respectively) and patients who died within 1 week (11%).Ang-2 plasma levels higher than 15 µ/mL account for 13 fold increased risk of death with 94% negative predictive value. Conclusions:Ang-2 plasma level at admission is predictive of early mortality and kidney, lung and hemostasis dysfunction in SIRS/sepsis patients newly admitted in a medical ward.
Background: Adequate stratification and scoring of risk is essential to optimize clinical practice; the ability to predict operative mortality and morbidity is important to choose the gold therapy and a proper use of resources.The Physiological And Operative Severity Score For The Evaluation Of Mortality And Morbility (POSSUM) has been proved to be the most appropriate scoring system in providing an estimation of postoperative mortality for patients undergoing abdominal surgery.The aim of our study was to verify the predictive accuracy of POSSUM in patients undergoing elective extrabdominal surgery.Patients and Methods: Our study included 189 patients, all admitted to Intensive Care Unit (ICU) at S.Andrea Hospital in Rome.The sample was divided in 2 groups: group A, abdominal surgery; group B, extrabdominal surgery.All types of surgery were included except for cardiac surgery, pediatric surgery and urgent surgery.For each patient was determined the POSSUM score.Age, sex and preoperative information, surgical diagnosis, severity of the procedure , time of hospitalization, post operative complications were also recorded.The two groups were divided in classes, based on the rate of morbidity and mortality.For each class was calculated the relation between predicted and observed deceases, and the relation between predicted and observed complications, scoring 1 if present and 0 if not present, in order to assign a reliability score to each group.Furthermore, basing on the length of stay, were individuated three subgroups of patients: hospitalization < 3 days, between 4 and 7 days, > 7 days.For each group was evaluated the correlation between observed and predicted morbidity.Results: Above 189 patients, 49 developed postoperative complications, with a real morbidity rate of 25,9% (95%CI: 20%-32%) and a predicted rate of 51,3%; the relation between observed and predicted complications (O/P ratio) was 0,50.For the A group the O/P ratio was 0,45, with a real morbidity rate of 25,53% (95% CI: 17%-34%) over a predicted rate of 56,4%.In the B group the O/P ratio was 0,53, with a real morbidity rate of 26,31% (95%CI: 17,2%-34,8%), and a predicted rate of 49%.Above 189 patients, 5 deceased, with a real mortality rate of 2,64% (95% CI: 0,4%-4,8%), over a predicted rate of 16,4%; the relation between observed and predicted deaths (O/P ratio) was 0,16.For the A group, O/P ratio was 0,11, with a real mortality rate of 2,1% (95% CI: 0-5%) over a predicted rate of 18,08%; for the B group, O/P ratio was 0,25, with a real rate of 3,16% (95% CI: 0-436,7%) over a predicted rate of 12,63%.Correlation between time of hospitalization and POSSUM morbidity has an average strength expressed by a ρ value = 0,4. Conclusion:Observed data confirm the possibility to extend the POSSUM score in the stratification of patients undergoing extrabdominal surgery.Even though it overpredicted the value of morbidity and mortality, as widely known, POS-SUM score shows an impressive uniformity and concordance between the main groups A and B. Furthermore, there is a good correlation between time of stay in ICU and the POSSUM morbidity.Our results suggest that POSSUM can be an adequate perioperative mean, recommended to evaluate the real condition of a patient after surgery and to determine the requirement of an admission to the postoperative ICU.
We present the case of a young lady who presented to the department of emergency medicine (DEM) for evaluation of painful breast swelling and skin indurations involving 90% of the body surface. She stayed long in the DEM for 3 days and managed for breast abscess she was consulted to dermatology for evaluation of skin lesions and prelimi- nary diagnosed as rare skin T cell lymphoma. Final diagnosis based on clinical and histopathological was Mycosis Fun- goids (MF).This case reveals that prompt referral from the DEM to the concerned speciality even for the rare type of dis- eases like MF can facilitate diagnosis and management and overall positive impact on disease outlook. Our patient was fi- nally admitted under oncology unit and managed appropriately.
Background: Early goal directed therapy (EGDT) can reduce mortality in an Intensive Care Unit (ICU) popula- tion with severe sepsis. It is not clear whether EGDT can be effectively implemented in an Emergency Department (ED) with existing resources to achieve the same goals. Objectives: To assess the impact of EGDT in our ED with existing resources on time to antibiotics (ABX) and patient out- comes. Methods: We performed a before and after study of the effects of the EGDT protocol on patients over age 21 with severe sepsis admitted to the ICU. Time to ABX was the primary outcome, mortality and other care processes were secondary. Descriptive statistics, Fisher's exact chi-square, and Wilcoxon rank sum tests compared time periods. Multivariate analy- ses with logistic and Cox proportional hazard regression models were performed. Results: 192 cases: 91 before and 101 after protocol. Groups were similar in demographics, co-morbidities, severity scores, and overall mortality of 17.7%. Patients with higher Mortality in ED scores (MEDS) received ABX sooner than patients with lower MEDS after adjusting for time period. There was no difference in time to ABX between time periods after adjusting for disease severity (Hazard Ratio: 0.88, 95% CI: 0.65-1.18; OR: 0.88, 95% CI: 0.49-1.57). Conclusion: Our EGDT protocol did not change management, time to ABX, or mortality of septic patients admitted to the ICU, when relying on existing resources. Further study is needed to evaluate barriers to EGDT and feasibility of translat- ing resource intensive protocols to the bedside in routine ED care.
We are describing a case of acute onset of amiodarone-related pulmonary toxicity (amiodarone lung) presented with clinical findings of acute ingravescent dyspnea, and reversed after prompt drug discontinuation.A concise review of the characteristics of pulmonary toxicity is also provided.Lung adverse effects may occur approximately in 5-17% of treated patients, and are usually associated with older age, duration of the treatment, cumulative dosage, and probably previous co-existing lung disease may play a role.Such adverse pulmonary effects may occur either early (few days after starting treatment) or after several years, and onset of symptoms may be slowly insidious or acute, and dramatically progressive.Thus, a high level of alertness is necessary in comorbid and elderly patients receiving amiodarone, even in an emergency setting, to consider this kind of adverse reaction among all possible differential diagnoses.
Background: Aortic dissection is a potentially fatal condition that primarily affects the older population.Rapid diagnosis of dissection is crucial for a favorable outcome and the only effective strategy to improve outcome is high clinical suspicion and prompt treatment.Objective: We present a case that demonstrates a timely diagnosis of a serious and life-threatening condition by an emergency bedside ultrasound (EBU).Case Report: We report a case of a 36-year-old male with prior history of cholelithiasis and frequent ED visits for biliary colic that presented with abdominal pain.An emergency bedside ultrasound showed gallstones and an aortic dissection in the abdominal aorta.Emergent surgical consultation was obtained based on the ultrasound finding, and subsequently followed with confirmatory imaging and surgical intervention. Conclusion:This case report highlights the utility of emergency bedside ultrasound, which made a timely diagnosis and saved a life.
Objective: To determine if women of reproductive age who present to the Emergency Department (ED) with urinary tract infection (UTI) symptoms can accurately predict their pregnancy status. Methods:We performed a retrospective study of women who presented to the ED with UTI symptoms (dysuria, frequency, or urgency).Consecutive females aged 18-49 years were referred from triage to a computer kiosk in the waiting room.The kiosk asked all patients in oral and written format: "Are you pregnant, worried you might be pregnant or have you missed your last period?"Patient responses about pregnancy risk were compared to urine pregnancy test results.Test characteristics and post-test probabilities were calculated.Results: From a total of 300 eligible subjects, 216 received a pregnancy test, of which 10 were positive, giving a pregnancy prevalence of 5%.Of 196 patients who reported no pregnancy risk, 4 were found to be pregnant, yielding a negative posttest probability of pregnancy = 2.0% (95%CI 0.8-5.1).Among the 155 women diagnosed with a UTI, 6 were pregnant, giving a prevalence of 4%.Of the 144 patients who reported no pregnancy risk, 2 were found to be pregnant, yielding a negative posttest probability of 1.4% (95% CI 0.4-4.9).Conclusions: Adult women presenting to the ED with UTI symptoms who report no pregnancy risk have a 2% or lower probability of actually being pregnant.We believe this level of accuracy to be sufficient for routine clinical practice, and consider it is reasonable to initiate empiric antibiotic therapy without diagnostic pregnancy testing in such patients.
Objective: Nonsteroidal anti-inflammatory drugs are considered the mainstay in the treatment of renal colic.Nonsteroidal anti-inflammatory drugs are contraindicated in patients with renal failure and are not recommended in patients with certain diseases.In these cases other analgesics should be used.The aim of our study was to compare the analgesic efficacy of intramuscular Diclofenac and Tramadol in the treatment of renal colic in our emergency department.Methods: A prospective, randomized trial was conducted in patients with a clinical picture of renal colic.Diagnosis was confirmed by non contrast abdominal computed tomography.Subjects were randomized to receive a single intramuscular injection of either 75 mg Diclofenac or 100 mg Tramadol.Ninety seven patients were included, of these 48 received Diclofenac and 49 received Tramadol.Results: Patients' characteristics including average stone size and degree of hydronephrosis were similar at enrollment.Diclofenac was significantly more effective than Tramadol in reducing the severity of pain at 30 minutes as measured on a 10-cm visual analogue scale.Reduction of more than 50% in pain severity was observed in 64% of patients treated with Diclofenac and in 49% of patients treated with Tramadol (P < 0.05).More patients in the Tramadol group needed rescue analgesia: 51% vs 21(p< 0.05).For all the study variables, Diclofenac was better than Tramadol Conclusions: Intramuscular Diclofenac as a single agent for the treatment of renal colic is more effective than intramuscular Tramadol in our patients.Intramuscular Tramadol may be an alternative when contraindications preclude the use of Diclofenac.
Objective: To evaluate the efficacy of a simple method to minimize gastric inflation in unprotected airways during resuscitation procedures. Methods: Ventilation of an airway simulator by use of a hose extended mask with leak and without leak and with or with- out additional oxygen (15 litres per minute). Experimental settings with artificial lung at a compliance = 300ml/ kPa and resistance = 0,5 kPa/ l/ s. Lower oesophageal sphincter pressure = 0,5 kPa. Results: Tidal volumes were significantly lower with integrated leak than with the leak proof mask (medians: 406 vs. 681ml), gastric inflation was significantly reduced by use of the mask with leak (medians: 2300 ml vs. 7300ml) and inspi- ratory oxygen fraction was significantly higher when oxygen was added. Conclusion: Gastric inflation may markedly be reduced, however not excluded, when a mask with a prefabricated leak is used instead of achieving a leak proof mask ventilation technique. With additive oxygen only the inspiratory oxygen frac- tion will be significantly higher which supports the benefit of additional oxygen.
The Authors report a case of a patient presenting in the Emergency Department (ED) with severe epigastric pain refractory to therapeutic treatment, with onset after forced ice water ingestion caused by joking compression of a soft PET ® bottle during drinking.The Angio MR and angiography performed, after exclusion of suspected esophagus rupture and other esophago-gastric diseases, to rule out an ischemic origin of the pain demonstrate a stenosis of the celiac artery resulting from median arcuate ligament narrowing, the so-called Dunbar's Syndrome.The Dunbar's Syndrome is uncommon and some aspects such as the vascular etiology of symptoms are still controversial.In this report clinical presentation, differential diagnosis and pathophysiology of this disease are discussed.
Norwegian scabies is a rare skin infestation by the mite Sarcoptes scabei var hominis.This condition typically presents with widespread, crusted lesions associated with hyperkeratotic scales.The elderly, the debilitated, and patients who are immunocompromised are at risk for this more severe form of scabies.The authors discuss the presentation, diagnosis, treatment and prevention of this dermatologic condition.
