I Congresso Nazionale Great Italia, Roma 19

Transcript

numero 2 - giugno 2011
editoriale
Trimestrale. Anno VII • Prezzo di copertina E 9,50 • Poste Italiane. Spedizione in A.P. D.L. 353/2003 (conv. in L. 27/02/2004 n° 46) art. 1, comma 1, DCB Torino n. 2/11. ISSN 18269826
Non-invasive Intensive Care in Pronto Soccorso e Medicina d'Urgenza
3 Nicola
Di Battista
clinica e terapia
5 Acute Pancreatitis: Pathophysiology, Clinical Aspects, Diagnosis e
Treatment
Raffaele Pezzilli, Bahjat Barakat, Dario Fabbri, Andrea Imbrogno, Mario Cavazza
10
Onset of angioedema following a viper bite: different options for
diagnostic procedure in an emergency department
Alessandro Riccardi, Pierangela Minuto, Anna Da Col, Viviana Panunzio, Roberto Lerza
13
Victims of Violence in Accident & Emergency: Reporting Survey of
Eleven Emergency Structures Out of Eighteen
Maria Pia Ruggieri, Anna Santa Guzzo, Massimo Magnanti, Giannantonio Cerqua
organizzazione e formazione
16 Emergency Contraception: a survey of Hospital Emergency
Departments Staffs
Marco Bo, Ivo Casagranda, Mario Galzerano, Lorena Charrier, Maria Michela Gianino
ATTI del
I Congresso nAzIonAle
greAT ITAlIA
19-21 ottobre 2010
roma
emergency
care
journal
sommario
Sommario
Editoriale ............................................................. 3
Clinica e terapia
Acute Pancreatitis: Pathophysiology, Clinical Aspects,
Diagnosis e Treatment
Raffaele Pezzilli, Bahjat Barakat, Dario Fabbri, Andrea
Imbrogno, Mario Cavazza ........................................ 5
emergency care journal - organizzazione, clinica, ricerca • Anno VI numero 2 • Giugno 2011 • www.ecj.it
Onset of angioedema following a viper bite: different
options for diagnostic procedure in an emergency
department
Alessandro Riccardi, Pierangela Minuto, Anna Da Col,
Viviana Panunzio, Roberto Lerza .............................. 10
Direttore responsabile:
I. Casagranda
Co-Direttori:
C. Locatelli, B. Tartaglino
Comitato Di reDazione
Federico Miglio, Massimo Pesenti Campagnoni,
Carlo Locatelli, Daniele Coen, Antonio Morra,
Anna Fagiani, Libero Barozzi, Paolo Carraro,
Paolo Danesino, Maurizio Mori, Franco Perraro,
Mauro Frascisco, Cristina Mazzoleni, Daniele Ebbli,
Giovanni Volpicelli, Mario Cavazza, Carolina Prevaldi
segreteria Di reDazione
Francesco Buccelletti, Enrico Ferri, Cristiano Lauritano,
Tiziano Lenzi, Michele Santoro
eDitore
C.G. Edizioni Medico Scientifiche s.r.l.
Via Candido Viberti, 7 - 10141 Torino, Italia
Tel. 011.33.85.07 r.a. - Fax 011.385.27.50
E-mail: [email protected]
Sito Web: www.cgems.it
stampa:
Ages Arti Grafiche s.r.l. - Torino
Finito di stampare il 20/06/2011
Emergency Care Journal, periodico ufficiale della società scientifica
AcEMC
Abbonamento 2011 presso C.G. Edizioni Medico Scientifiche: € 44,00
Versamento sul c/c postale n. 339101 oppure tramite
assegno bancario non trasferibile intestato
a C.G. Edizioni Medico Scientifiche s.r.l.
Registrazione al Tribunale di Torino per Emergency Care Journal n. 5935
del 17/01/2006. Poste Italiane. Spedizione in A.p. DL 353/2003 (conv. in
L. 27/02/2004 n. 46) art. 1, comma 1, DCB Torino.
Victims of Violence in Accident & Emergency:
Reporting Survey of Eleven Emergency Structures Out
of Eighteen
Maria Pia Ruggieri, Anna Santa Guzzo, Massimo
Magnanti, Giannantonio Cerqua ............................... 13
Organizzazione e formazione
Emergency Contraception: a survey of Hospital
Emergency Departments Staffs
Marco Bo, Ivo Casagranda, Mario Galzerano, Lorena
Charrier, Maria Michela Gianino .............................. 16
Atti del I Congresso Nazionale Great Italia 2010 ... 22
AVVERTENZE: si fa presente che l’IVA è assolta all’origine
dall’Editore a norma dell’art. 74 comma 1/C - DPR 633/1972.
Inoltre gli articoli 1 e 5 del DM 29 dicembre 1989 esonerano gli Editori dall’emissione di fatture per la cessione di pubblicazioni per le quali è stato scelto il regime forfettario.
© Copyright by C.G. Edizioni Medico Scientifiche s.r.l. Torino. Tutti i diritti di proprietà letteraria e artistica sono riservati, compreso quello di
traduzione. Nessuna parte della rivista può essere riprodotta, contenuta in
un sistema di recupero o trasmessa in ogni forma e con ogni mezzo elettronico, meccanico, di fotocopia, incisione o altrimenti, senza permesso
scritto dell’Editore.
Emergency Care Journal non è affiliata con nessuna
Industria Farmaceutica o con Produttori di strumenti medicali
Fotocopie per uso personale del Lettore possono essere effettuate nei
limiti del 15% di ciascun fascicolo di periodico dietro pagamento alla
SIAE del compenso previsto dall’art. 68, comma 4, della Legge 22
aprile 1941 n. 633 ovvero dall’accordo stipulato tra SIAE, AIE, SNS,
e CNA, CONFARTIGIANATO, CASA, CLAAI, CONFCOMMERCIO,
CONFESERCENTI il 18 dicembre 2000. Le riproduzioni per uso differente da quello personale potranno avvenire solo a seguito di specifica autorizzazione rilasciata dall’Editore.
Per ricevere senza alcun impegno maggiori chiarimenti, è a disposizione il Servizio Assistenza Clienti attivo dal lunedì al venerdì dalle
9,00 alle 12,30 e dalle 13,30 alle 17,30.
2
Materiale protetto da copyright. Non fotocopiare o distribuire elettronicamente senza l’autorizzazione scritta dell’editore.
emergency
care
journal
editoriale
Non-invasive Intensive Care in Pronto Soccorso e Medicina
d'Urgenza
Nicola Di Battista
Tissue is the issue
“Tissue is the issue” è il messaggio operativo che da alcuni anni
la cultura intensivistica promuove in modo pressante verso tutti
i professionisti che operano nel settore dell’urgenza. Il nocciolo della questione sta nella cellula: ovvero il trattamento di un
paziente “critico” impone che ogni sforzo diagnostico e/o terapeutico debba sempre essere indirizzato all’ottimizzazione della
perfusione cellulare, vero ed unico terminale, al fine di salvaguardarne il metabolismo. In una logica fortemente interdisciplinare, ogni competenza specialistica coinvolta deve ribaltare
il proprio approccio metodologico, ovvero operare una sorta
di rivoluzione copernicana: in emergenza il consueto baricentro degli interessi diagnostici e terapeutici, rappresentato dalla
tradizionale centralità toracica (cuore e polmoni) deve saper
cedere il passo alla “periferia” ovvero alla cellula; meglio, al mitocondrio. L’ottimizzazione della funzione cellulare costituisce
il prerequisito necessario ed indispensabile per un controllo del
danno d’organo in essere ed in possibile rapida evoluzione. Senza tale chiarezza di obiettivi da perseguire, ogni nostro tentativo
rischia di essere vanificato.
La minore invasività possibile
Negli ultimi due decenni il rapporto costo-beneficio degli interventi intensivistici invasivi, inteso soprattutto in termini di
salute, ha messo in chiara evidenza i rischi derivanti dalle possibili complicanze cui ogni manovra invasiva è esposta. La minore
disponibilità economica, contemporanea all’aumento dei costi
degli interventi sanitari, ha favorito un interesse ed un’attenzione crescenti nei confronti della tecnologia non-invasiva.
L’acquisizione di una buona conoscenza scientifica e fisiopatologica della medicina intensiva, integrata con l’utilizzo di tecnologia innovativa non invasiva, ha offerto al medico dell’urgenza
una preziosissima opportunità di crescita culturale, di identificazione professionale e di revisione organizzativa del proprio
campo di azione. Ottenere in modalità non-invasiva e in tempo
reale informazioni sicure concernenti a) la perfusione e respirazione cellulare, b) l’output cardiaco, c) le resistenze vascolari
periferiche, (oltre a quelle ormai consolidate, quali gli scambi
polmonari, la ventilazione, l’equilibrio acido-base etc.) significa
poter inquadrare il paziente instabile più rapidamente; ne deriva
un più precoce ed appropriato trattamento.
La stessa diatriba societaria, protrattasi peraltro a lungo, tra
medici d’urgenza ed anestesisti-rianimatori viene a svuotarsi
di ogni significato pretestuoso quando i professionisti coinvolti
nell’emergenza siano in grado di riscoprire, con reciproco rispetto, i rispettivi campi di azione, caratterizzati essenzialmente dalla tipologia di minore o maggiore invasività delle manovre e del
monitoraggio attivati. Una comune e condivisa cultura intensivistica costituisce l’unica strada possibile per il conseguimento:
1. di un elevato filtro in ingresso verso le terapie intensive, e
quindi di una maggiore appropriatezza del loro impiego, 2. di un
precoce inquadramento emodinamico, e quindi di una maggiore
efficacia dell’intervento terapeutico 3. di una migliore comprensione fisiopatologica del timing in cui l’intervento terapeutico
si inserisce, e quindi di un suo più efficiente monitoraggio, 4.
di una più efficace continuità assistenziale del paziente critico,
e quindi di un suo outcome più favorevole, 5. di una riduzione
dei costi assistenziali globali, e quindi di una possibile sostenibilità economica. Una comune cultura ed un reciproco riconoscimento dei rispettivi ruoli favoriscono una forte integrazione
strategica, senza la quale l’organizzazione dell’emergenza appare
fortemente compromessa. È auspicabile altresì un coinvolgimento culturale e tecnologico esteso anche alle altre competenze specialistiche dell’Ospedale per Acuti; ne conseguirebbe
una migliore integrazione interdisciplinare, un più appropriato
coinvolgimento del rianimatore in caso di emergenza intraospedaliera, ed una più fluida dismissione del paziente acuto dal settore dell’emergenza verso le altre aree ad elevata intensità di cura
dell’ospedale: il tutto a vantaggio dell’iter del paziente “acuto”
che altrimenti rischia di essere incanalato in percorsi intensivistici più o meno invasivi, e sicuramente a più elevato costo,
economico e di salute.
La Formazione
Diretta conseguenza delle considerazioni sopra esposte è la necessità di rendere fruibili ed accessibili a tutti i professionisti
che operano in urgenza i fondamenti dell’emodinamica, al fine
di rendere immediatamente interpretabili i dati forniti in tempo
reale dalla tecnologica non-invasiva. Una cultura che va in questa
direzione permette di trattare, in ogni area ad elevata intensità di
cura dell’ospedale, pazienti “critici” con livelli di monitoraggio
assistenziale inferiori. Soltanto una piattaforma culturale comune, seppure diversificata nei ruoli che i vari professionisti rivestono, riesce a creare le condizioni per una rapida acquisizione delle
nuove metodiche. Diventano necessari pertanto percorsi formativi, di diverso livello di conoscenza, che però mirano a medesimi
obiettivi. Si ritiene che anche concetti che appaiono inizialmente
ostici, se opportunamente “banalizzati”, possono essere compresi
ed assimilati da tutti, ovviamente in misura proporzionale alle
conoscenze di base possedute.
È altrettanto evidente che i principi di base dell’emodinamica,
ovvero di perfusione e respirazione cellulare non possono assolutamente prescindere dalla conoscenza dei principi fisiopatologici
che regolano i meccanismi di ossigenazione e ventilazione, essendo le tre funzioni (ossigenazione, ventilazione e perfusione) fortemente interdipendenti tra loro. Una propedeuticità nell’acquisizione delle informazioni, e quindi dei processi formativi, diventa
tassativa. La ricca offerta formativa di AcEMC vuole andare in
questa direzione.
Un possibile modello
In un contesto generale di ridotta disponibilità economica e di
lievitazione dei costi, soltanto la sinergia tra a) un livello più
elevato delle conoscenze, b) una implementazione dell’impiego
di tecnologia innovativa non-invasiva e c) una forte integrazione professionale ed umana tra le diverse competenze coinvolte, può condurre ad una riduzione del rischio clinico e ad un
miglioramento della qualità dell’assistenza, o almeno al mantenimento degli standard sinora raggiunti. Questa sinergia deve
essere trasversale nell’intero ospedale; costituisce fattore critico
nelle aree ad elevata intensità di cura.
La Medicina d’Urgenza occupa una sorta di pole position nel-
emergency care journal - organizzazione, clinica, ricerca • Anno VII numero 2 • Giugno 2011 • www.ecj.it
SC Medicina d'Urgenza - Ospedale di Faenza (RA)
3
editoriale
toraggio non-invasivo; tutto questo costituisce il prerequisito
indispensabile, ma non sufficiente. Necessitano altresì: una
buona intesa tra tutti i professionisti (medici ed infermieri),
un clima di lavoro sereno, la consapevolezza da parte dei medici del proprio obbligo morale allo studio, accompagnato da
una certa curiosità verso la ricerca; ma soprattutto necessita
un atteggiamento di personale disponibilità verso la sofferenza
del paziente. Questo nuovo modo di interpretare il lavoro del
medico d’urgenza e, se si vuole, la stessa cultura dell’urgenza,
prefigura a mio parere la nascita di una sorta di Non-invasive
Intensive Care, con caratteristiche essenzialmente funzionali,
che sia disponibile all’occorrenza per qualsiasi paziente critico,
ovunque egli si trovi.
la filiera dei reparti ad elevata intensità di cura; ad essa spetta essenzialmente il triplice compito 1. di supportare il Pronto
Soccorso alla ottimizzazione del filtro dei ricoveri, utilizzando
anche la funzione dell’Osservazione Breve Intensiva, 2 di stabilizzare il paziente “critico” prima di una dismissione verso
altri reparti, 3. di effettuare ricoveri di breve durata. Anche in
assenza di aree strutturate, specificamente dedicate a tali funzioni, è possibile realizzare questo triplice obiettivo, purché i
posti letto disponibili siano particolarmente versatili a realizzare le diverse funzioni appena esposte. A questo scopo ogni
posto letto deve poter ospitare qualsivoglia patologia più o
meno critica e, all’occorrenza, deve poter essere attrezzato con
monitor centralizzato, per ottenere un buon livello di moni-
4
emergency
care
journal
clinica e terapia
Acute Pancreatitis: Pathophysiology, Clinical Aspects,
Diagnosis e Treatment
Raffaele Pezzilli, Bahjat Barakat*, Dario Fabbri, Andrea Imbrogno*, Mario Cavazza**
Pancreas Unit, Department of Digestive Diseases and Internal Medicine, *Emergency Department Sant’Orsola-Malpighi Hospital, Bologna
Acute pancreatitis is an acute inflammation of the pancreas. The
clinical classification of the disease recognizes the mild acute
pancreatitis, characterized by the absence of local and/or systemic
complications, and the severe disease, characterized by the presence
of local complications such as necrosis, abscess or pseudocysts and/
or distant organ failure. Gallstones constitute the predominant
etiological factor. The severity assessment is essential for proper
initial treatment of the disease. Primary objectives to achieve in
the treatment of acute pancreatitis essentially are: pain control,
electrolyte support and energy intake, removal of the causal agent,
attenuation of the inflammation, and prevention and eventual
treatment of local and systemic complications of necrotizing forms.
Keywords: Acute pancreatitis; Disease management; Severity
assessment; Therapy.
Introduction
necrosis. Computed tomography with intravenous contrast bolus is currently the best diagnostic method (accuracy 80-90%).
Pancreatic necrosis rarely involves the entire gland in its entire
thickness; usually it remains confined to the periphery and spares the glandular core. Haemorrhagic foci are present in varying
degrees. The necrosis may become infected (10-30% of cases)
and the distinction between sterile and infected pancreatic necrosis is important because the therapeutic approach (mainly
medical therapy in sterile pancreatic necrosis, surgical in the
infected type) and prognosis (mortality rate about three times
higher in infected pancreatic necrosis) differ considerably. The
diagnostic gold-standard for suspected infection of pancreatic
necrosis is represented by microbial cultures of material from
percutaneous needle aspiration (Figure 2).
Acute fluid collection is a localized effusion in or near the pancreas, without granulation fibrous wall. It tends to appear early and
regresses spontaneously in most cases. It is not considered a sign
of disease severity unless it becomes infected.
Pseudocysts is a collection of pancreatic juice enclosed by a wall
lacking epithelialization and appearing as a result of acute pancreatitis, chronic pancreatitis or pancreatic trauma. The maturation of a pseudocyst after acute pancreatitis requires at least
4 weeks after the onset of the disease. A post-acute pancreatitis
pseudocyst is therefore an acute fluid collection persisting more
than 4 weeks surrounded by a well-defined wall (Figure 3).
Walled-off pancreatic necrosis is an intra-abdominal collection
of pus (usually near the pancreas), appearing after an attack of
acute pancreatitis or after pancreatic trauma. Pus predominates
and there is only small amount of necrotic tissue, distinguishing
it from non-infected pancreatic necrosis. A pseudocyst presenting pus within its walls is also correctly defined as a walled-off
pancreatic necrosis [3].
Acute pancreatitis is an acute inflammation of the pancreas with
variable involvement of peripancreatic tissues and/or distant organs. The inflammatory process may be limited to the pancreatic
gland with edema or necrosis, or it may involve the surrounding
tissues and/or distant organs, so the clinical manifestations range from mild abdominal pain to very serious presentations with
high mortality rate [1]. Episodes of acute pancreatitis in patients
who will subsequently develop anatomical, clinical and functional features compatible with chronic pancreatitis are classified
as the former until the final diagnosis is established. The now
widely accepted classification of the disease and its complications is a clinical classification prominently known as the Atlanta classification [2] and is shown below.
Mild acute pancreatitis is characterized by a favorable clinical
course in the absence of local and/or systemic complications.
The predominant pathological expression is interstitial edema
more or less associated with peripancreatic steatonecrosis (Figure 1).
Severe acute pancreatitis is characterized by the presence of local complications such as necrosis, abscess or pseudocysts and
/ or organ failure. In most cases it is the clinical expression of
the presence of pancreatic necrosis; in fact, patients with acute edematous-interstitial pancreatitis rarely present a clinically
severe form of the disease. The organ failure was defined as
shock (systolic blood pressure < 90 mmHg), pulmonary insufficiency (PaO2 < 60 mmHg), renal failure (serum creatinine >
2 mg/dl after rehydration) or gastrointestinal bleeding (> 500
cc/24h).
Pancreatic necrosis is a focal or diffuse area of non-viable parenchyma, which typically is associated with peripancreatic steato-
ABSTRACT
5
Fig. 1 - Multidetector computer tomography: edematous pancreatitis.
clinica e terapia
clinica e terapia
Fig. 2 - Multidetector computer tomography: Necrotizing pancreatitis.
Pathophysiology
There are many recognized causes of acute pancreatitis, but surely gallstones constitute the predominant etiological factor in
our geographical area [4]. Less frequently, acute pancreatitis is
related to chronic use or abuse of alcohol and even more rarely
is secondary to abdominal surgery, diagnostic and/or interventional endoscopical procedures on the papilla of Vater, abdominal trauma, dyslipidemia or the use of drugs with pancreatic
toxicity [5-7]. The mechanisms by which the various etiological
factors trigger pancreatic inflammation have not yet been fully identified but it seems proved with sufficient certainty that,
whatever the initial pathogenic noxious stimuli, the earliest pathogenetic events are triggered inside the acinar cells [8] . Under
normal conditions these cells produce digestive enzymes and
lysosomal enzymes, the former segregated in lysosomal vacuoles, the latter in the vacuoles of zymogen. In acute pancreatitis
this strict compartmentalization can be overridden by alteration
of a complex biological process, calcium-dependent, defined as
“stimulus-secretion coupling”. A colocalization of lysosomes
and zymogen granules in a unique vacuole is thus determined:
the lysosomal enzyme cathepsin B can activate trypsinogen at
this point with consequent cascade activation of other proteases and phospholipases. It follows the rupture of vacuoles, cell
damage, necrosis and release of cellular activated enzymes in
the interstitium. Local processes of vasoconstriction-dilatation
determine infiltration of inflammatory cells and increased necrosis. In the most severe forms of acute pancreatitis it is present
a complex biochemical cellular and humoral response not substantially different from what happens in other serious diseases
such as septic shock, the poly-trauma and extensive burns. The
magnitude and the continuation of such events, assignable to
the so-called SIRS (systemic inflammatory response syndrome),
affect the extent and severity of local damage and progression
to systemic complications [9]. Implicated mediators are various
cytokines such as interleukin-1 (IL-1), IL-6, IL-8, TNF (tumor
necrosis factor), PAF (platelet activating factor) [9,10]. All these
mediators are markedly elevated in the first 24 hours of illness,
whereas the anti-inflammatory cytokines to (IL-2, IL-10) are reduced. The result is the activation of neutrophils, monocytes,
lymphocytes, platelets and endothelial cells. The increased expression of cell adhesion molecules and integrins on neutrophils
results in increased adhesion to the endothelium, diapedesis and
invasion of distant organs (first of all the lungs) where hyperactive neutrophils call forth other polymorphonuclear leukocytes
and result in extensive tissue destruction [11]. The presence of
trypsin, chymotrypsin and elastase in the pancreatic interstitium, in serum and peritoneal fluid is responsible for activation
Fig. 3 - Ultrasonography:
pancreatitis pseudocyst (Ps)
The main pancreatic duct is
dilated (W).
6
of the coagulation-fibrinolysis systems, endothelial cells, PMN
leukocytes and monocytes-macrophages with synthesis and release of cytokines, superoxide ions and PAF [8]. The latter is
a key mediator capable of stimulating the release of other proinflammatory cytokines, increase vascular permeability, induce
a negative inotropic effect, leukocyte chemotaxis, tissue edema
and cellular damage. It is possible to clearly appreciate the possibility of a serious involvement of distant organs up to the development of the “fearsome” multi-organ failure syndrome.
outcome [15]. From these simple evaluations are derived three
important corollaries:
a) the majority of patients benefits from a conservative therapy,
not surgery,
b) the early identification of those patients at increased risk of
developing complications is crucial for prognosis and therapy;
c) surgical therapy is to be reserved for those patients who
develop specific complications, primarily the infection of
pancreatic necrosis and / or peripancreatic fluid collections.
Evaluation and stratification of
severity of acute pancreatitis
Essentially, the severity of an acute attack leads to the development of a necrotizing form of the disease and pancreatic necrosis
is not only responsible for the clinical severity, but also the onset
of complications and, ultimately, mortality. At the present state
of knowledge a severe form of acute pancreatitis can not adequately be dealt without the support of a CT scan available full-time
and other multi-specialistic skills/human resources and equipment. The guidelines of the British Society of Gastroenterology
[16] and the Italian of the Italian Association for the Study of
the Pancreas [12] suggest that a specialized center for the treatment of severe acute pancreatitis should have the following
characteristics:
1. allocation in a general hospital where the major medical and
surgical specialties are present;
2. multidisciplinary team with specialists in Internal Medicine,
Surgery, Endoscopy, Critical Care and Intensive Care and
Pathology,
3. day and night availability of CT and ultrasound with staff
expert in percutaneous treatments, the availability of magnetic resonance and angiography may be useful but not
essential,
4. the presence of daytime endoscopists experienced in endoscopic retrograde cholangiopancreatography (ERCP) and
related interventional procedures.
Severity assessment is essential for proper initial treatment in
the management of acute pancreatitis and this constitutes a
recommendation of grade A in the Italian guidelines on acute
pancreatitis [12]. These guidelines also suggest that assessment
of severity should be done by a scoring system such as Acute
Physiology and Chronic Health Evaluation (APACHE) II [12]:
an APACHE-II score greater than 8 is important for determining treatment policy and identifying the need for transfer to
a referral unit. Serum C-reactive protein values grater than 150
mg/dL are useful for severity assessment, but they may not reflect severity within the first 48 h after onset. In addition contrast-enhanced CT scanning and contrast- enhanced MRI play
an important role in severity assessment. The CT severity index, as proposed by Balthazar et al. [13], should be used. In
fact, the gold-standard for the presence of pancreatic necrosis
is the computed tomography (CT) with intravenous contrast
medium, which should be done after 72 hours from pain onset
and after rehydration of the patient; it may be possibly repeated
according to the clinical situation. Management in, or referral
to, high-volume units is necessary for patients with extensive
necrotizing pancreatitis or other complications who may require
care in the intensive therapy unit or interventional radiological,
endoscopic or surgical procedures and this constitutes a recommendation of grade B [12].
Therapy
Background
One of the recurring features of acute pancreatitis is the frequent
presence of a variably long period of time, sometimes days,
between the onset of symptoms and hospitalization. This is a
factor that affects the very effectiveness of therapeutic measures
and ensures that treatment is more often aimed at controlling
the progression of the disease rather than at interfering with
initial pathogenetic phenomena. The delay in hospital makes it
difficult to interpret results of therapeutic trials and impossible
a homogeneous analysis of aggregate data from multiple studies,
as the timing of treatment is often not specified, or the onset
of symptoms is considered at the time of hospitalization. The
time frame in which there is a reasonable chance of specifically
antagonize the inflammatory mediators and activated pancreatic
enzymes to mitigate or prevent the development of a partial or
total impairment of distant organs is about 2-3 days after the
onset of pain and this period is also called interventional window [14]. All this should lead to a “specific” treatment as early
as possible and at the same time confirms that it is absolutely
unnecessary and wasteful to use these same drugs in patients
who come late to the observation, often in the second week of
illness, at a stage where there are already signs of impairment
of distant organs. In this clinical scenario, treatment should be
more rationally targeted toward measures useful in supporting
cardiovascular, respiratory and renal systems and preventing
septic complications. It is possible to affirm that for every four
patients with acute pancreatitis, three will respond favorably to
conservative medical treatment, while the fourth will present
complications with a one in three chance of suffering a fatal
Objectives and methods of conservative treatment
Primary objectives to achieve in the treatment of acute pancreatitis essentially are:
1. pain control,
2. electrolyte support and energy intake,
3. removal of the causal agent, when possible,
4. attenuation of inflammatory and autolytic processes at the
glandular level (“specific” therapy),
5. prevention and eventual treatment of local and systemic
complications of necrotizing forms.
For mild forms of disease, in most cases the first three steps are
sufficient for clinical resolution. In severe forms, the therapeutic
engagement is more complex and patients may, with reasonable
frequency, require periods of hospitalization in intensive care
units. The therapeutic approach to severe acute pancreatitis is
reported in Figure 4.
The control of pain must be swift and effective: for this purpose,
meperidine is the drug of choice [15].
Supportive therapy is a measure of fundamental importance that
counterbalances the seizure of the fluids and hypercatabolism particularly important in severe forms. The maintenance of cardiovascular parameters, renal and respiratory can in many cases prevent
the onset of multisystem complications. The pancreatic hypoperfusion, secondary to inadequate maintenance of plasma volume is
indeed able to trigger and increase the phenomena of pancreatic
necrosis. Patients with mild forms, for which it is expected an oral
refeeding within 4-6 days of hospitalization, do not need an aggressive nutritional approach [15]. In contrast, in severe forms total parenteral nutrition (TPN) must be used, which must take into
account in its formulation of any metabolic imbalances (such as
acidosis or alkalosis, hyperglycemia, hypocalcemia, and hypokalemia ipomagenesiemia) and cardiovascular complications [15].
Recently, enteral nutrition through naso-jejunal probe has been
used with good results in patients with severe acute pancreatitis
clinica e terapia
7
clinica e terapia
instead of the NPT. The pathophysiological assumption is that the
NPT does not provide all essential nutrients (eg glutamine) and
does not fuction as intestinal barrier which can increase intestinal
permeability to toxins and bacterial translocation.
The early removal of the causative agent makes it paramount to
achieve a sufficiently precise etiologic diagnosis and early intervention. In clinical practice, this translates, at least in our population, in the identification of a mechanism for biliary obstruction, transient or persistent, complete or partial, in about 2/3
of cases. The removal of biliary obstruction using endoscopic
techniques has now entered into the routine treatment of these
patients.[12, 16]. The “specific” therapy of acute pancreatitis relies on antisecretory and antiprotease drugs.
The use of somatostatin and its synthetic analogue octreotide is
much debated. The results of published studies, many uncontrolled and with small case series or not stratified by severity
of illness, are controversial, although a metanalytical evaluation
shows, in general, a therapeutic advantage. From the theoretical point of view, the negative effects of vasoconstriction of the
splanchnic circulation and contraction of the sphincter of Oddi
outstripped the hypothetical beneficial effects related to inhibition of exocrine pancreatic secretion.
Among antiprotease drugs the gabexate mesylate showed a positive effect in patients with severe acute pancreatitis, with significant reduction of systemic complications and the need for
surgery but not mortality compared with placebo. The dosage
used in early studies was 3 g/day by continuous intravenous infusion, but subsequently it was found that a dose of 1.5 g/day in
the same manner for a period of treatment of 7-8 days is also a
viable option [17]. The best results are obtained when the administration starts earlier than the onset of symptoms.
The use of systemic antibiotics for the prevention of pancreatic
infections is one of the cornerstones of conservative treatment
of severe forms of acute pancreatitis. Several studies have shown
a significant reduction in the incidence of pancreatic and extrapancreatic infections but not mortality in patients treated with
imipenem-cilastatin [18]. Quinolones, due to their pharmacokinetic characteristics and their range of action, should ensure an
effective prophylactic action as well. However, in a recent randomized prospective trial, patients treated with pefloxacin showed an incidence of infected necrosis significantly higher than
patients treated with imipenem (34% vs 10%) [19]. At present,
therefore, it is recommended for all patients with acute necrotizing pancreatitis an early administration of imipenem-cilastatin
at a dose of 1.5-2 g/day, lasting for at least two weeks.
Objectives and indications of surgical treatment
The infection of pancreatic necrosis in the course of acute pancreatitis is a very serious medical condition and its presence is
associated with a marked increase in risk of death; it developes
in percentages varying from 15 to 70% of all patients with acute
necrotizing pancreatitis and accounts for more than 80% of
deaths from acute pancreatitis. The risk of infection increases
with the extent of necrosis and the days after initiation of acute
pancreatitis, reaching a peak incidence (70%) after three weeks
[20]. In most cases the infection is caused by Gram-negative
bacteria of enteric origin, and about two thirds of infections are
caused by a single microbiological agent. Therefore, E. coli is the
most frequent causative agent (26%), followed by Pseudomonas, Klebsiella and Proteus species. Frequently Gram positive
infections are also detected, such as Staph.aureus (15%), Streptococcus faecalis and Enterococcus or other anaerobic bacteria,
and in some cases by fungi. In clinical terms acute pancreatitis
with sterile necrosis can be difficult to distinguish from a form
with infected necrosis, because both can give fever, leukocytosis and abdominal pain. But this distinction is very important,
since the mortality in patients with infected necrosis that did not
underwent early surgery is high. TC or ultrasound-guided percutaneous suction of the necrotic material and/or peripancreatic fluid collections, with a fresh microscopic examination and
bacterial culture, is safe and accurate (sensitivity and specificity exceeding 95%) and must be used, even repetitively, usually
from the second week of illness, in patients whose clinical condition worsens or does not tend to improve, despite the removal
of any causative agent and the implementation of a vigorous
supportive treatment. Debridement is the surgical treatment of
choice of infected necrosis and the only therapeutic doubt concerns the type of intervention to perform (classic necrosectomy
with drainage-washing or open packing technique). Recently
other treatment options, such as percutaneous, endoscopic or
minimally invasive surgery have been proposed [21-23]. These
methods require highly experienced operators, are not risk-free
and should be for the moment limited to patients unfit for surgery because of a high anesthetic risk.
8
Fig. 4 - Therapeutic approach
to severe acute p ancreatitis.
The treatment of patients with sterile pancreatic necrosis remains controversial. Surgical treatment offers no demonstrable
survival benefits compared with supportive treatment; in addition, because the surgery may cause postoperative infection
of necrotic tissue in 25-50% of cases with a very high secondary mortality, a surgical indication in any case sterile necrosis
should be considered with prudence and care. Even when the
necrotic process determines rupture of the main pancreatic duct
and necrosis remains sterile, there are good prospects for a resolution of the disease with conservative therapy. The precise role
of surgery in the treatment of sterile necrosis is therefore limited
and should be reserved for selected cases, such as those patients
in whom repeated attempts at oral re-feeding after 5-6 weeks of
therapy are associated with abdominal pain, nausea, vomiting or
recurring pancreatitis. At this stage of the disease, however, generally necrosis is more demarcated and the surgical act is easier.
In other cases, supportive care associated with prophylactic antibiotic treatment should be the primary treatment [24-28]. It is
therefore very important to perform in due time (possibly during the same hospitalization for mild forms, usually at a distance
of three to four weeks for severe) a cholecystectomy in case of
gallstones in order to prevent recurrence of acute episodes [12].
clinica e terapia
13.
14.
15.
16.
17.
18.
19.
20.
References
1. Steinberg W, Tanner S. Acute pancreatitis. New Engl. J. Med
1994; 330: 1198-210.
2. Bradley EL. A clinically based classification system for acute
pancreatitis. Arch Surg. 1993, 128: 586-90.
3. Stamatakos M, Stefanaki C, Kontzoglou K, Stergiopoulos S,
G Giannopoulos, M. Safioleas Walled-off pancreatic necrosis. World J Gastroenterol 2010; 16:1707-12.
4. Pezzilli R, Uomo G, Gabbrielli A, Zerbi A, Frullone L, De Rai
P, Castoldi L, Cavallini G, Di Carlo V; Proinfa-AISP Study
Group. A prospective multi-center survey on the treatment
of acute pancreatitis in Italy. Dig Liver Dis 2007; 39:838-46.
5. Pezzilli R, Cecilia R, Corinaldesi R, Barakat B. Acute pancreatitis two to simvastatin therapy: Increased severity after
rechallenge. Dig Liver Dis 2004; 36:639-40.
6. Pezzilli R, Morselli-Labate AM, Corinaldesi R. NSAIDs and
acute pancreatitis: A Systematic Review. Pharmaceuticals
2010; 3: 558-571.
7. Pezzilli R, Corinaldesi R, Morselli-Labate AM. Tyrosine kinase inhibitors and acute pancreatitis. JOP 2010; 11:291-3.
8. Pezzilli R, Romboli E, Campana D, Corinaldesi R. Mechanisms Involved in the onset of post-ERCP pancreatitis. JOP.
2002; 3:162-8.
9. Kusse AM Rongions AJ, Reber HA Cytokines and acute pancreatitis. Gastroenterology 1996; 110: 639-41.
10. Pezzilli R, L Bellacosa, Felicani C. Lung injury in acute pancreatitis. JOP 2009; 10:481-4.
11. Rinderknecht H. Genetic determinants of mortality in acute
necrotizing pancreatitis. Int J. Pancreatol. 1994, 16: 11-8.
12. Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Delle Fave GF and
the Working Group of the Italian Association for the Study
21.
22.
23.
24.
25.
26.
27.
28.
of the Pancreas on Acute Pancreatitis. Practical guidelines
for acute pancreatitis. Pancreatology 2010;10:523-35.
Balthazar EJ, Freeny PC, van Sonnenberg E. Imaging and
intervention in acute pancreatitis.Radiology 1994; 193:
297–306.
Makhija R, Kingsnorth AN. Cytokine storm in acute pancreatitis. Pancreatitis J Hepatobiliary Surg 2002; 9:401-10.
Pezzilli R. Pharmacotherapy for acute pancreatitis. Expert
Opin Pharmacother. 2009, 10:2999-3014.
UK guidelines for the management of acute pancreatitis.
Gut 1998; 42 (s-2): 1-13.
Pezzilli R, Miglioli M. Multicentre comparative study of two
schedules of gabexate mesilate in the treatment of acute
pancreatitis. Italian Acute Pancreatitis Study Group. Dig
Liver Dis 2001, 33:49-57.
Villatoro E, Bassi C, Larvin M. Against Antibiotic therapy for
prophylaxis of pancreatic necrosis infection in acute pancreatitis. Cochrane Database Syst Rev 2006; 4: CD002941.
Bassi C, Falconi M, Talamini G, Uomo G, G Papaccio, Dervenis C, Salvia R, Minelli EB, Pederzoli P. Controlled clinical
trial of pefloxacin versus imipenem in severe acute pancreatitis. Gastroenterology 1998, 115:1513-7.
Beger HG, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis. A prospective clinical study.
Gastroenterology 1986; 91:433-8.
Schoenberg MH, Rau B, Beger HG. New Approaches in surgical management of severe acute pancreatitis. Digestion
1999; 60 (s-1): 22-6.
Bakker OJ, van Santvoort HC, Besselink MG, van der Harst E,
Hofker HS, Gooszen HG; Dutch Pancreatitis Study Group. Prevention, detection, and management of infected necrosis in severe acute pancreatitis. Curr Gastroenterol Rep 2009; 11:104-10.
Santvoort van HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF,
van Eijck CH, Bollen TL, van Ramshorst B, VB Nieuwenhuijs
, R Timmer, Laméris JS, Kruyt PM, Manusama ER, van der
Harst E, van der Schelling GP, Karsten T, Hesselink EJ, van
Laarhoven CJ, Rosman C, Bossche K, de Wit RJ, Houdijk AP,
van Leeuwen MS, Buskens E, Gooszen HG; Dutch Pancreatitis
Study Group. A step-up approach or open necrosectomy for
necrotizing pancreatitis. N Engl J Med 2010, 362:1491-502.
Baron TH, Morgan DE. Acute necrotizing pancreatitis. N.
Engl. J. Med 1999; 340: 1412-15.
Steinberg WM, Bradley EL, Warshaw AL. Indications for
debridement of necrotizing pancreatitis. Pancreas 1996; 13:
219-23.
Bradley EL. Operative vs. nonoperative therapy in necrotizing pancreatitis. Digestion 1999; 60 (s-1): 19-21.
Bassi C, Falconi M, Sartor N, Bonora A, Caldiron E, Butturini G et al. The role of surgery in the early Major Complications of severe acute pancreatitis. Eur.J.Gastroenterol.
Hepatol. 1997, 9: 131-6.
Banks PA. Practice guidelines in acute pancreatitis. Am J.
Gastroenterol. 1997, 92: 377-86.
clinica e terapia
9
clinica e terapia
Onset of angioedema following a viper bite: different
options for diagnostic procedure in an emergency
department
Alessandro Riccardi, Pierangela Minuto, Anna Da Col, Viviana Panunzio*, Roberto Lerza
SC Pronto Soccorso e Medicina e Chirurgia d’Accettazione e d’Urgenza, Ospedale San Paolo, Savona, Italy
*SC Immunoematologia e Medicina Trasfusionale, ASL 2 Savonese, Savona, Italy
ABSTRACT
10
The unexpected onset of an angioedema in a patient observed in the
emergency department after a viper bite, gave the opportunity to consider some different etiopathogenetic hypothesis and to discuss the most
correct diagnostic procedure. The patient was a 60-year-old man who
was treated with sartans for hypertension and reported a recent diag-
nosis of monoclonal gammopathy of uncertain significance. Based on
the patient history and on the clinical aspects of the angioedema, the
authors consider the possibility of an acquired non-allergic angioedema
and its probable close relationship with a lymphoproliferative disorder.
Keywords: angioedema, viper bite, emergency department.
Introduction
Among the first adopted measures antimicrobial prophylaxis
with amoxicilline/clavulanate was started and antitetanus
gammaglobulins were administered. The patient was then admitted
to our ward for a short time of observation. After ten hours from
his admission, during the night, the patient showed a sudden
onset of a non-inflammatory oedema of the face, in particular
of the palpebral region and lips (fig. 1a, b), and of the hands.
Legs, foot and genitals were not involved. Breathing and vital
parameters were not impaired, there was however only a slight
involvement of the mucosa of tongue and throat. Then steroids,
antihistamines and epinephrine were administered intravenously.
All symptoms fully disappeared without complications within 24
hours. The patient told physicians that this episode was similar
to those he had periodically complained in the last two years.
A direct relationship between the snake venom and the onset of
angioedema was excluded by the consultant of the Anti-poison
Centre (Fondazione Maugeri-Pavia). The viper bite had only
locally induced a slight haematoma confined to the upper part of
the left foot (fig. 2).
The patient was discharged about 48 hours after the admission,
and he was addressed to a further haematological and allergologic
evaluation with the aim to reconsider the diagnosis of MGUS and
to perform specific immunological tests. The latter confirmed the
presence of a serum monoclonal paraprotein IgMk and showed
the positivity of the Bence Jones protein. The value of serum IgM
was increased (1182 mg/dl normal range 47-230), IgA were 139
mg/dl (90-395) and IgG 696 mg/dl (840-1660). The level of the
C1-inhibitor (C1-INH) resulted at the lowest level of the normal
range. This is possible because there is a report of a lymphomaassociated angioedema with normal plasma concentration of
C1-INH (4) and in lymphoproliferative disease it is hypothized
that auto-antibodies to C1-INH make the protein functionally
inactive or increase its catabolism (3). The M component might
correspond to the anti-C1-INH auto-antibodies (5). To definitely
confirm a diagnosis of acquired angioedema, reduced C1q
molecule levels, normal level of C3 and a low C4 should be
detected together with the demonstration of a decreased C1-INH
plasma concentration or activity, but only few centers are able to
give reliable results.
Finally, the bone marrow biopsy showed the presence of a small
monoclonal population of B lymphocytes. Phenotypically the cells
expressed CD5, CD19, CD20, CD22 , were negative for CD10,
CD 23 and restricted for k chains in a picture suggestive for a
mature B cells lymphoproliferative disorder.
Angioedema is a life-threatening clinical condition because of the
mucosal swelling of the upper airways which may impair breathing. Face, neck, limbs, genitals and the gastrointestinal mucosa
can be involved by a recurrent unpredictable oedema. The pathophysiology of allergic angioedema recognizes a histamine-mediated mechanism, and consequently a pruritic oedema and urticaria
are typically detected. On the contrary, non-allergic angioedema
symptoms are generally mediated by a bradykinin release, and
urticaria and/or inflammatory and pruritic swelling are classically absent. Five different types of non-allergic angioedema are
defined in literature (1). They include hereditary, acquired, idiopathic, pseudo-allergic, and renin-angiotensin-aldosteron system
blocker-induced angioedema. Among these, acquired angioedema
is considered a rare condition (2, 3); however, its incidence is
probably underestimated and frequently unrecognized. The pathophysiology of this condition reflects a non-genetic C1-esterase
inhibitor (C1-INH) defective activity due to decreased plasma levels or impaired function (1). Here we present a case of a possibly
acquired angioedema, which was an interesting opportunity for the
emergency physicians to discuss the different hypothesis of the
diagnostic procedure
Case report
A 64-years-old man was seen for the first time in our emergency room
in September 2010 because of a viper bite involving the fifth finger
of the left foot. He had had a history of hypertension treated with
angiotensin II receptor antagonist (candesartan) for approximately
ten years. He reported a recent diagnosis of monoclonal gammopathy
of uncertain significance (MGUS) IgMk made by a haematologist,
and he had been submitted to many allergologic tests because in the
last two years he had experienced sporadic and transient episodes,
characterized by stuffy nose and swelling in the palpebral region.
The checks results were negative and no specific agent had been
found as precipitating factor. When admitted in the emergency room,
he denied any known allergy. No physician had seen and visited the
patient during the described episodes. At the time of admission he
appeared in good general conditions, his physical examination was
inexpressive, the vital parameters and the basic laboratory findings
were normal. A slight haematoma was present at the fifth finger of
the left foot together with small signs from the snake bites. The
patient had killed the snake and taken it to the hospital.
Fig. 1 - Non-inflammatory oedema of the face (a) and lips (b).
(7,8). According to this statement, a snake bite can be considered a
minor trauma that certainly induces an emotional stress.
In our patient two aspects were of importance in addressing the
diagnosis toward a non-allergic angioedema. The first one was
the absence of anamnestic data suggestive for a known allergy:
allergologic cutaneous and blood tests previously carried out
resulted negative. The second one is the typical non-inflammatory
cutaneous swelling that wasn’t itchy or painful. The lack of
signs of urticaria further support the hypothesis of a non-allergic
angioedema (1). Among the different types of the latter condition
a hereditary angioedema seems unlikely due to the absence of
family history, the age of the patient and the relatively recent time
of beginning of the disorder. It is well known that angioedema can
be an important side effect not only of the angiotensin-converting
enzyme inhibitors therapy, but also of a treatment with sartans
(9-11). We think it was correct to advise the patient to stop the
drug even if he had taken sartans for more than ten years, and
then a correlation with the appearance of angioedema did not seem
believable.
On the basis of the considerations reported so far, we were more
and more suspicious of a possible close relationship between the
MGUS and the angioedema. In our patient both the first episode
of angioedema and the diagnosis of MGUS were approximately
of the same period. Moreover, monoclonal gammopathies,
lymphoproliferative syndromes, autoimmune diseases, neoplasms
and infections have been reported as diseases associated with
acquired angioedema (3, 12). Although not frequently reported,
lymphoproliferative disorders of mature B-lymphocytes
expressing IgM kappa or lambda are the prominent disorders
underlying an acquired angioedema (3, 13-15), and the latter is an
important, potentially life-threatening complication of lymphoma.
It is also important a prompt suspicion and recognition of these
conditions, because an appropriate treatment of the associated
disease could resolve angioedema in some patients (3). Obviously,
in an emergency department there is no possibility to study these
cases deeply from a haematological and immunological point of
view, but it’s important to think of this possible association and
to correctly address the patient to a diagnostic procedure. In an
emergency setting it is not unusual to see repeatedly the same
patient with episodic angioedema, but often the emergency
physicians are not involved and informed of the final diagnosis,
while their role is limited to the surveillance of the vital functions
and the observation of patients who frequently have a self-limiting
disturbance. We were extremely satisfied by the fact that, in the
presented case, the emergency physician was the first one to
hypothize the correct diagnosis and to put haematologist and
allergologist in contact, in order to consider the close relationship
between the two conditions they had separately evaluated.
Discussion
Facing the onset of an angioedema physicians should ask
themselves some questions. First of all, it is important to establish
if the angioedema has an allergic or a non-allergic cause. The snake
poison, the administration of antibiotics and gammaglobulin as
anti-tetanus prophylaxis could theoretically be antigens inducing
a histamine-mediated allergic angioedema. However, in our case
this appears an unlikely etiopathogenetic hypothesis, because the
patient complained recurrent episodes of angioedema in the last
two years apart from the exposure to specific agents. Moreover,
the Anti-poison Centre excluded a relationship between the viper
venom and the angioedema, and literature reports only of some
cases of angioedema following specific antivento treatment (6).
We agree with the Anti-poison Centre, but trying to explain the
coincidence between the viper bite and the episode of angioedema
is suggestive to consider the snake bite as a precipitating stressing
event. In fact, the old term “angioneurotic oedema” derived from
the opinion that in non-allergic angioedema precipitating factors
included minor trauma, estrogen, infection and emotional stress
clinica e terapia
11
Fig. 2 - Haematoma of the left foot induced by the viper bite.
clinica e terapia
References
1. Bas M, Adams V, Suvorava T, Niehues T, Hoffmann TK,
Kojda G. Non allergic angioedema: role of bradykinin.
Allergy 2007;62:842-56.
2. Zingale LC, Castelli R, Zanichelli A, Cicardi M. Acquired
deficiency of the inhibitor of the first complement component:
presentation, diagnosis, corse and conventional management.
Immunol Allergy Clin North Am 2006;26:669-90.
3. Cicardi M, Zanichelli A. Acquired angioedema. Allergy
Asthma & Clin Immunol 2010;6:1492-96.
4. Gaur S, Cooley J, Aish L, Weinstein R. Lymphoma-associated
paraneoplastic angioedema with normal C1-inhibitor activity
: does danazol work? Am J Hematol 2004;77:296-98.
5. Cicardi M, Beretta A, Colombo M, Gioffre D, Cugno M,
Agostoni A. Relevance of lymphoproliferative disorders and
anti-C1 inhibitor autoantibodies in acquired angioedema. Clin
Exp Immunol 1996;106:475-80.
6. Stahel E, Wellauer R, Freyvogel TA. Poisoning By domestic
viper (vipera berus and vipera aspis). A retrospective study of
113 patients. Schweitz Med Wochenschr 1985;115:890-96.
7. Baxi S, Dinakkar C. Urticaria and angioedema. Immunol
Allergy Clin North Am 2005;25:353-67.
8. Fay A, Abinum M. Current management of hereditary
angioedema. J Clin Pathol 2002;55:266-70.
9. Roskiewicz F, Andriamanana I, Gras-Champel V, Andrejak
10.
11.
12.
13.
14.
15.
M, Massy ZA. Iatrogenic angioedema: the role of angiotensin
converting enzyme inhibitor and angiotensin II receptor
blockers. Nephrol Ther 2007;3:89-95.
Malde B, Regalado J, Greenberger PA. Investigation of
angioedema associated with the use of angiotensin-converting
enzyme inhibitors and angiotensin receptor blokers. Ann
Allergy Asthma Immunol 2007;98:57-63.
Haymore BR, Yoon J, MikitaCP, Klote MM, DeZee KJ. Risk
of angioedema with angiotensin receptor blockers in patients
with prior angioedema associated with angiotensin-converting
enzyme inhibitors: a meta-analysis. Ann Allergy Asthma
Immunol 2008;101:495-9.
Nettis E, Colanardi MC,Loria MP, Vacca A. Acquired
C1 inhibitor deficiency in a patient with systemic lupus
erythematosus: a case report and review of the literature. Eur
J Clin Invest 2005;35:781-4.
Bain BJ, Catovsky D, Ewan PW. Acquired angioedema as a
presenting feature of lymphoproliferative disorders of mature
B-Lymphocytes. Cancer 1993;72:3318-22.
Bibi-Triki T, Eclache V, Frilay Y, Stirnemann J, FremeauxBacchi V, Fain O. Acquired C1 inhibitor deficiency associated
with lymphoproliferative disorders: four cases. Rev Med
Interne 2004;25:667-72.
Wellwood J, Taylor K, Wright S, Bentley M, Eliadis P.
Angioedema in the emergency department: a presentation of
lymphoma. Emerg Med (Fremantle) 2001;13:465-8
12
clinica e terapia
Victims of Violence in Accident & Emergency: Reporting
Survey of Eleven Emergency Structures Out of Eighteen
Maria Pia Ruggieri*, Anna Santa Guzzo**, Massimo Magnanti*, Giannantonio Cerqua*
*UOC Medicina I per l’Urgenza, Azienda Ospedaliera San Giovanni Addolorata di Roma
**UOC Medicina d’Urgenza e PS A.U. Policlinico Umberto 1° Sapienza Università di Roma
Sexual violence is a widespread and common phenomenon in our
society, which unfortunately often goes unreported or undetected: a
hidden “iceberg” of great dimension. Often the victims arrive to our
emergency department where the sanitary workers are not prepared
to help them professionally. By this work the authors want to evaluate
health workers true understanding of the “problem of violence”; their
human and professional capacity to manage it; their capacity to create
and promote sensitisation and training programmes for professionals
working in the field; and the ability to design and implement protocols
and procedures to be utilized when managing victims of violence by a
questionnaire compiled and distributed to health professionals working in the critical areas (A&E and DEA) in the region Lazio.
Keywords: sexual violence, victims of violence, critical areas, emergency department
Introduction
questionnaire was divided into six distinct sections, each containing
questions designed to illicit data regarding particular aspects.
The first section evaluated the subject population of the study
by identifying: professional role - doctor or nurse, gender (male
or female), age in years, number of years of experience working
within the critical areas, the professional department they
belonged to i.e. Accident & Emergency, Department of Emergency
and Admissions or other.
The second section evaluated health workers understanding of the
problem of ‘violence’ by using the “triage colour code” system. This
has been in use in all A&Es and DEAs in the Lazio Region since
2008 (6), implemented following a training programme delivered
by experts and the Public Health Agency. Thanks to the single triage
model and a unique regional database system (GIPSE) used in all
A&Es and DEAs it is possible to evaluate the competency of health
workers through their attribution of the triage colour code system.
The third section evaluates the health workers level of understanding
of the medical-legal aspects associated with the problem of ‘violence’
by utilising the indicator “referred to the judicial authorities (JA)”,
taking into account that the law requires “… an obligatory medical
report to be made to the judicial authorities to include contributions
from all health professionals who have assessed or treated the referent”.
The fourth section evaluates how the organization perceives and
manages the problem “violence”, whether there is a management
model in place for victims of violence and if so whether it is
general knowledge to all the health workers in the structure. This
evaluation is conducted using the indicator “presence/absence of
management protocol for victims of abuse”.
The fifth section evaluates the specific “violence” training for
health workers through the indicator “attendance/non-attendance
at specific related training”.
The sixth and final section evaluates the sensibility of health
workers towards dealing with this area through the indicator
“proposal to improve/correct”.
The questionnaire was distributed by colleagues doctors from
Head Office SIMEU Lazio of different hospitals to 330 health
professionals working in the critical areas, included doctors,
nurses and midwifes.
Sexual violence is a widespread and common phenomenon in our
society, which unfortunately often goes unreported or undetected:
a hidden “iceberg” of great dimension. Different forms of rape,
sexual abuse and blackmail exist, these can occur inside the family
environment, externally or both (1).
When one speaks of “types of violence” one refers to the different
forms of violence: physical (ill-treatment), sexual (molestation,
rape, exploitation), psychological (violation of oneself), economical
(denying access to the economic resources of the family, even if earned
by the victim) (2, 3).
The 2006 ISTAT Survey, commissioned by the Ministry of Equal Rights
and Opportunities (4, 5), has thrown light on some disturbing numerical
data: from a sample of 25,000 women ranging in age from 16-70 years,
6,743,000 were victims of physical or sexual violence (31.9%); 5 million
were victims of sexual violence (23.7%); 3.961.000 were victims of
physical violence (18.8%); 6.092.000 were victims of psychological
violence from their current partner (36.9%); 1.100.000 were victims of
‘stalking’, that is they had been constantly followed or harassed.
In 2006 there were 74 thousand reported cases of rape or attempted
rape, 69.7% of these offences had been committed by the victims
partner or ex-partner. Abuse at home is very common place but often
these acts are not perceived as abuse.
Only 18.2% of victims are aware that the abuse they have endured are
criminal offences, while 44% simply judge the abuse as ‘something
wrong’ and 36% as ‘something that happened’.
The proportion of episodes of violence which are reported is low
(12.4%). The proportion increases when women have contact with
Accident and Emergency (62.3%), Police, lawyers, and magistrates
(47.6%) and doctors or nurses (35.9%).
Based on this epidemiological data, it was decided to conduct an
investigation in the Accident and Emergency units (A&E) and the
Departments of Emergency and Admissions (DEA) in the Lazio
Region. The aim of the investigation was to: evaluate health workers
true understanding of the “problem of violence”; their human and
professional capacity to manage it; their capacity to create and promote
sensitisation and training programmes for professionals working
in the field; and the ability to design and implement protocols and
procedures to be utilized when managing victims of violence.
A questionnaire was distributed to nurses and doctors working in the
critical areas (A&Es and DEAs).
Materials and Methodology
A questionnaire was compiled and distributed to health
professionals working in the critical areas (A&E and DEA). The
Results
Eleven structures out of a possible eighteen (61%) agreed to
participate in the survey (2 A&E units, 7 DEAs level I and 2 DEAs
level II) four of these were situated in the provinces of Rome and
the remainder in the city itself. A total of 330 questionnaires were
distributed, of these 293 (89%) were compiled and returned. The
subject sample who participated in the survey included doctors,
ABSTRACT
13
clinica e terapia
•
Reception of victims of violence by health workers in A&E to
maximise trust.
The request for better information, also from hospitals where
specific protocols have been put in place, where often the
implementation of the protocol is inhibited by poorly trained
health workers or the complete absence of dedicated space.
Discussion
Figure 1 - Results “Triage Colour Codes awarded for reported or
overt violence”. % Triage “Reported or Overt Violence”
14
Fgure 2 - Results “Triage Colour Codes awarded for Suspected Violence”. % Triage “Suspected Violence”
nurses and midwifes, who had an average age of 40 and an average
of 8.96 years work experience in the critical area under observation.
Analysing the correct award of colour codes in accordance with
the Lazio Triage Model (LTM), for a patient with “reported or overt
violence”, 49.8% of the questionnaire respondents awarded code
yellow, 25.9% code red and 6.1% code green (see figure 1) (7)
this represents an evident underestimate of the importance of this
category compared to the LTM where a patient with “reported or
overt violence” corresponds to a priority code red (see figure 2) (7).
The colour code awarded for a patient with “suspected violence”
also resulted in errors compared to the requirements of the LTM
where “suspected violence” corresponds to a priority yellow code
(see appendix n°1) (6), however, 47.4% of the questionnaire
respondents awarded code yellow, 5.4% code red, 25.2% code
green and 1.3% code white (see figure 3) (7).
Half of the health workers participating in the survey believed that
referral to the Judicial Authorities was the sole responsibility of a
doctor, 41% believed it was the sole responsibility of a nurse and
9% did not express an opinion.
From the returned questionnaires it emerged that 7 of the 11
A&E/DEA structures did not have a protocol for the management
of victims of violence; where a protocol was in place not all of
the health workers knew of its existence; those who knew of its
existence were unsure whether the protocol had been approved by
the Hospital Mangers, by the Chief Physician or both.
Only 21.8% of the health workers reported that they had
received an adequate training in the field of “violence”, whilst
53.9% believed they had an adequate psychological attitude to
receive victims; unfortunately, however, only 25.5% suggested
or proposed alternatives or improvements to the way victims of
violence are managed; those received included:
• Training for the health workers with “Telephone Rosa”;
• The creation of a direct route for victims from A&E to
structures in the area;
• Sensitisation and training to be constant and continuous for
health workers in A&E;
From analysing the data gained from the questionnaire it emerged
that medical and nursing staff who work in A&Es and DEAs in the
Lazio Region, even though middle-aged and with good relevant
work experience, lack the technical, professional and relationship
training to successfully manage victims of violence. This scarcity
in training together with a work context where too often protocols
for the management of victims of violence are inexistent protocols which should be foreordained, shared and implemented
by the senior managers and chief physicians of the structures. This
situation is unfortunately widespread within A&Es and DEAs both
within the city of Rome and its provinces. Furthermore, in spite
of the methodology of the LTM, designed to protect possible and
probable victims of violence, through the award of a code red or
yellow to guarantee priority of treatment and cure, regardless if
they are overt or suspected victims of violence and independent
of whether their vital functions have been compromised, the triage
nurses tend to underestimate these patients – proof of an enormous
scarcity in sensibility and attention to duty from the health workers
themselves and the health authorities more generally.
As regards possible limitations of the study and source of errors
the authors think that the possible bias could be searched in
the number of questionnaires distributed which are not known;
certainly they were much more that those collected. But this is not
so important for the finality of the study because even if the number
of collected questionnaires is fewer, they have demonstrated:
1) the absolutely absence of protocols for the management of
victims of violence,
2) where there is a protocol is unknown from medical and
nursing staff who work in A&Es and DEAs,
3) the absence of uniformity about the colour of triage, even if
there is a regional sanitary educational and training project
about triage from years.
Conclusions
In the view of the authors, which is supported by national and
international experience reported in research literature (8-10), this
situation could change through the constitution of a group of experts,
doctors and nurses, working in the field of emergency treatment in
Figure 3 - Algorithm Lazio Triage Model
the Lazio Region, committed to create, in collaboration with the
relevant institutions and in particular the Public Health Agency:
a) a unique protocol for the management of victims of abuse to
be implemented in all the Regions A&Es and DEAs (both level
I and II);
b) a training course, in collaboration with Voluntary Organisations
and experts in the field, for all staff working in critical areas
with periodical re-training;
c) a register of victims (data collection for active monitoring and
quality control);
d) a network of assistance for victims after discharge from
hospital to be organised in collaboration with anti-violence
centres in Roma and its Provinces.
In addition the authors hope that with this project it will be
possible to develop hearth workers’ skills and ability to: identify,
receive, listen to and initiate a helping relationship to respond to
clinical and care needs of women who are victims of violence.
In other words it is hoped that in the context of a dedicated
diagnosis, care and treatment, violence becomes “a problem of
Public Health, to be tackled with an interdisciplinary and scientific
approach, that includes and integrates: medicine, epidemiology,
sociology, psychology, criminology, education and economy” (11),
a guarantee of ethics, humanity and professionalism.
Bibliography
1. Guidelines for medico-legal care for victims of sexual violence.
(WHO) Geneva 2003.
2. Geneva Centre for the Democratic Control of Armed Forces
(DCAF). Women in an Insecure World. Violence against
Women. Facts, Figures and Analysis. Edited by Vlachovd and
Lea Biason. 2005.
3. Muratore MG, Sabbadini LL. Italian survey on violence
against woman. Statistical Journal of the United Nation ECE
22;2005:265-278.
4. Istat – Indagine Multiscopo, Sicurezza delle donne, 2006.
5. Istat. La violenza ed i maltrattamenti contro le donne dentro e fuori
dalla famiglia 2006. Conferenza-evento a Palazzo Chigi, 2007.
6. Il Triage Ospedaliero, a cura del Gruppo “Triage Lazio” e Lazio
Sanità Agenzia di sanità Pubblica. Edizione novembre 2007;
pag. 148-150.
7. Ruggieri MP. La violenza sulla donna. IV Congresso Regionale
SIMEU Nuove Prospettive Clinico-Organizzative; 20-21
novembre 2009 Roma.
8. Mincigrucci M. Gli strumenti di documentazione: il rapporto
medico, i protocolli d’intesa. Servizio Consultoriale Azienda
Sanitaria dell’Umbria USL n. 2.
9. Houry D, Cunningham RM, Hankin A, James T, Bernstein
E, Hargarten S. Violence Prevention in the Emergency
Department: Future Research Priorities. Academic Emergency
Medicine 2009;16:1089-1095.
10. Linee Guida assistenza sanitaria, medico-legale, psico-sociale
nelle situazioni di violenza alle donne e ai bambini, a cura del
SVS “Soccorso Violenza Sessuale” Provincia di Milano. 2006.
11. World Report on Violence and Health, (WHO), Geneva 2002.
clinica e terapia
15
emergency
care
journal
Emergency Contraception: a survey of Hospital Emergency
Departments Staffs
Marco Bo*, Ivo Casagranda**, Mario Galzerano***, Lorena Charrier***, Maria Michela Gianino***
* Legal Medicine Unit, University of Turin, Italy
** Emergency Department, S.S. Antonio e Biagio e Cesare Arrigo Hospital Trust, Alessandria, Italy
*** Department Public Health, University of Turin, Italy
ABSTRACT
16
The World Health Organization defines emergency contraception
(EC) as a means to prevent unwanted pregnancy. In countries where
EC is dispensed behind the counter, emergency departments are a
preferred point of care for its prescription and dispensing. In light
of this situation and as no studies on emergency contraception in
emergency departments in Italy have been conducted to date, this
study was designed with a view to analyze the responses of emergency room physicians in relation to their prescribing habits and
knowledge about the drug and in relation to frequency and profile of
women arriving for care at hospital emergency departments in Piedmont and requesting prescription for the morning-after pill. This
cross-sectional survey involved 29 hospital emergency departments
in Piedmont where no gynecologists are on active duty. The survey
instrument was a 24-item questionnaire. Analysis of responses revealed that in the physicians’ opinion the vast majority of requests
came from Italian nationals (97%) ranging in age from 18 to 30
years (76%), single and not cohabiting with a partner (60%), and
nulliparous (64.0%). Women mostly request EC for first-time and
the most common reasons were condom breakage or slippage. Just
over half the physicians (52%) stated that emergency contraception prescription was not an appropriate part of care provided at
an emergency department and 72% stated they felt uneasy about
prescribing emergency contraception. The survey also revealed gaps
in physician knowledge about the pharmacokinetic and pharmacodynamic properties of emergency contraception pills.
Introduction
Emergency contraception (EC) refers to the use of drugs or intrauterine devices (IUD) to prevent unwanted pregnancy after an
unprotected sexual intercourse.
The World Health Organization (WHO) defines EC as a means to
prevent an unwanted pregnancy which constitutes an important
risk factor for a woman’s health.
Studies in Europe and the United States investigating the characteristics of requests for EC prescription have found that the
majority are made by young women (<30 years of age), single
or nulliparous, with a middle-to-high education level (1-6). Requests are most frequent during the summer months (June to
September), around holidays (e.g., New Year’s) and the weekend
(Saturday to Monday) (3,4,7) and within the first 24 hours after
sexual intercourse (3,5,7) .
In light of these data, in countries where EC is dispensed behind
the counter, emergency departments are a preferred point of care for
its prescription and administration: emergency department services
are operated around the clock, hold a supply of the drug and, in
some instances, may be an ideal setting for educating women about
safe sex practices and how to prevent sexually transmitted infections (STIs) (8). For these reasons, studies have investigated the
propensity of emergency department medical staff to dispense EC.
In 1995 Gbolade (9) administered a questionnaire to the heads
of ED in the United Kingdom to find out what they felt about
prescribing EC. Analysis of the responses revealed that only 57%
prescribed EC, despite their knowing that the pill had to be taken within 72 hours after sexual intercourse, since they didn’t
believe it an appropriate part of emergency room services and
didn’t consider unprotected sexual intercourse an unexpected urgent accident. If the emergency physician on duty was unwilling
to administer the pill, the women were referred to their general
practitioner, a family-planning center or in some cases to a gyne-
cologist on duty, especially during the weekend. Drawing from
these responses, the study concluded that refusal to offer EC was
linked to several factors, including the physician’s personal ethos
and knowledge about the drug.
A similar study conducted in Oregon in 2003 (10), which also
employed a questionnaire, found that physician attitudes differed
depending on whether the woman had been sexually assaulted
or had consented to unprotected intercourse: 46% of emergency
physicians did not provide EC to women requesting it, if they had
consented to unprotected intercourse; the women were referred
to another medical facility where they could obtain EC.
The same questionnaire was later administered to a sample of medical staff in New Mexico (11): in 21% of cases, the request was
motivated by consensual unprotected intercourse and in 52% by
an episode of sexual assault; in 13% of cases, the women were
referred to an external health care provider, and in 15% they received neither a prescription nor a referral to another medical facility,
despite the medical staff’s knowing the time limit for effective EC.
A 2005 national telephone survey in which anonymous requests
for EC were made to 600 emergency departments in the U.S. (12)
revealed that EC was never offered at 42% of non-Roman Catholic
hospitals or at 55% of Roman Catholic hospitals; in 45% of the
latter, EC was offered only to sexual assault victims and after the
woman had undergone specific procedures - pregnancy testing
and police reports - but still at the discretion of the physician on
duty. In instances of refusal to provide EC, the physician referred the woman to an external health provider in only 50% of cases, without being sure in 80% of such cases whether the facility
would in fact offer EC. An additional finding was that emergency
department medical staff was poorly informed about EC.
While there are data about EC prescription practices in European
countries and the U.S., no data are available for Italy where EC
is dispensed behind the counter. To fill this gap, we conducted
this study in emergency departments in Piedmont. The study was
conducted within the framework of targeted research and was
funded by the Piedmont Region.
The aims of the study were to analyze the responses of emergency
department medical staff in relation to: 1) EC prescription, specifically with regard to behavior toward the prescription requests
and to the prescriber’s degree of knowledge about the modes of
prescription and administration of the drug 2) the frequency and
profile of women arriving for care at emergency departments and
requesting prescription of the morning-after pill.
Unlike many U.S. studies investigating differences in physician
behavior according to whether they work in a Roman Catholic hospital or a non-Roman Catholic hospital, our study did not address
this issue as no church-run hospitals are operated in Piedmont.
Materials and methods
With this study we used a cross-sectional survey involving 29
emergency departments of hospitals in Piedmont where no gynecologist is on duty. The study period ran the full 2009 calendar
year. The survey was conducted using a 24-item questionnaire subdivided into eight areas (Table 1-2). Fourteen items were drawn
from international sources and published evidence-based medicine data. Table 3 lists the bibliographic references for each of these
items. The remaining 10 items were designed to gain a broader
view of the characteristics of women requesting EC prescriptions,
the temporal distribution of requests and medical staff knowledge
about EC and prescribing behaviors. The questionnaire was administered to emergency department medical staff in participating
Piedmont hospitals and took about 30 minutes to complete.
The emergency department medical staff was composed of emergency physicians. This choice was operated to avoid bias linked to
specialist knowledge which could have generated an insight bias.
For this reason, the ED of the obstetrics and gynecologic hospital
(Regina Margherita-Sant’Anna Hospital), the trauma center (Hospitals CTO-Maria Adelaide) and the ophthalmic hospital (Sperino Hospital) were excluded from the study.
Statistical analysis
Descriptive statistical analysis was carried out to calculate the
mean and frequency distribution of data. Pearson’s Chi-squared
test was applied to responses to the items investigating the characteristics of the women requesting EC. This was done to determine whether there was a relationship between the following
variables: age and nationality; age and main reason for requesting
EC; civil status and main reason for requesting EC.
The same test was performed to reveal a possible influence of
emergency department level (I or II) on: peak time of year and
peak day during the week for EC requests; civil status of the women requesting EC; history of previous voluntary abortions; frequency of EC use and number of requests made.
With regard to questions about the pharmacokinetic and pharmacodynamic knowledge, physicians’ responses were dichotomized into
correct and incorrect answer. Univariate analysis were conducted
to assess whether sex, age and ED level were associated with the
correct answer using the Chi-square test (for sex and ED level) and
t-student test for age. In the case where there was a univariate association, this one was examined in multivariate analysis (logistic regression) in which the dependent variable was the correctness of the
response and the independent variables were age, sex and ED level.
The data were processed using SPSS vers. 16 software for Windows.
Results
The data were collected from questionnaire responses by 75 emergency physicians (Table 1). Response data are tabulated in Table 2.
Analysis of the responses revealed that 68% of physicians had received
from 1 to 20 requests and 24.0% had received 21-40 requests. The
weighted average number of requests in 2009 was an estimated 1250.
In physicians’ opinion, requests were most often made by Italian
nationals (97%) between 18 and 30 years of age (76%) followed
by those aged between 14 and 17 years (18.7%). Most of these
women were described as single, not cohabiting with a partner
(60.0%) and nulliparous (64%). In most instances, first-time requests for EC (57.3%) because of “Condom breakage, slippage or
incorrect use” (50%) or “Unprotected sexual intercourse” (42%)
were reported. According to ED staff, in 66.0% of cases requests
came from women who had been refused a prescription by another health care provider, chiefly physicians in out of hours service
(48%). While non-specific seasonality for requests could be determined, peak times around the weekend (73.3%) were reported.
Just over half (52%) of medical staff considered prescribing the
morning-after pill as an inappropriate part of emergency department services. This attitude was widely held among physicians
working in level I and level II emergency departments, irrespective of where the hospital was located in the region.
Many physicians felt at odds with providing EC: 72% stated that
they felt “Very uncomfortable, slightly uncomfortable or fairly
comfortable” about writing out a prescription. Nonetheless,
70.7% said they prescribed EC and gave information about contraception methods. Some 57.3% stated that when asked, a physician should always prescribe EC, whereas 25.3% believed that a
physician could affirm the right of conscientious objection on the
grounds of the Deontological Code, and 13.3% in recognition of
the provisions of Law 194/78 regulating legal abortion. According to responses to items investigating the prescriber’s knowledge
about the pharmacokinetics of EC, 62.7% stated that the pill had
to be taken with 72 hours after unprotected intercourse, 37.3%
gave no time limit, and 4% stated that the pill could be taken
within 120 hours after unprotected intercourse. Only 17.3% correctly knew the time window within which the drug needs to be
taken in order to be most effective (12-24 hours after unprotected
intercourse, as reported in the literature) (13).
The survey also revealed the prescribers’ patchy knowledge about
the drug’s pharmacodynamics: 96% knew that the pill does not
usually cause significant side effects but may cause nausea, vomiting and headache; 80% were aware that diagnostic tests before
prescribing it are not required; only 52% correctly remembered
the mode of assumption; 11% believed that EC use can lead to
an increase in risky sexual behavior and STIs; 20.6% stated that it
can result in giving up the use of regular contraception.
One important aspect concerned the responses investigating
knowledge about the pill’s mechanism of action: 70.7% believed
that it has a complex mechanism of action that involves inhibition of ovulation and fecundation, alteration of tubal ciliar motility and sperm motility, and inhibition of embryo implantation,
whereas 17.3% thought it inhibited ovulation, as occurs with
other contraceptives.
Statistical analysis revealed a statistically significant relationship
between the woman’s age and nationality (p=0.0001) and between
Table 1.
Profile of emergency department physicians (AREA 1):
Sex
Male (%)
56.8
Female (%)
43.2
Mean age ±SD
(yrs)
44.2±7.4 [range, 32-59]
Levels of emergency department*
Level I (45.7%)
Level II (54.3%)
Location of emergency department
In a hospital in a
provincial or regional
seat (49.3%)
In a hospital in
another town/city
(50.7%)
Level II is more advanced than Level I
17
Table 2
Frequency distribution of physicians’ responses
AREA 2: Number and frequency distribution of EC
prescription requests
%*
Nulliparous
64
Parous
0
1,3
Unknown
30,7
1-20
68
8. History of previous elective abortion
21-40
24
Yes
4
41-80
5,3
No
30,7
80-150
0
Unknown
60
>150
0
9. EC prescription requested by a woman who:
Unknown
1,4
Requested EC for the first time
57,3
Requested EC in the past
22,7
Unknown
20
1. How many requests for the morning-after pill did you
receive in the past year?
0
2. In which period of the year were requests most frequent?
Winter
6,7
10.The main reason for requesting EC prescription was:
Spring
13,3
Condom breakage, slippage or incorrect use
50,3
Summer
8
2,7
Forgot to use another method of contraception or the
method failed
6,7
Autumn
None of the above
69,3
Unprotected sexual intercourse
42
Unknown
1
3. On which days were requests most frequent?
Monday
2,7
Tuesday through Friday
2,7
Weekend
73,3
Monday through Friday
0
Tuesday through Sunday
5,3
Weekend through Monday
1,3
None of the above
4
AREA 3: Demographics of women requesting EC prescription
4. Woman’s age (years)
AREA 5: Prescriber’s knowledge about the EC pill’s pharmacokinetics
11. In which of the following circumstances do you believe
providing the morning-after pill is indicated:
Unprotected sexual intercourse in the 120 hours preceding
the request
6,7
Unprotected sexual intercourse in fertile period
9,3
Unprotected sexual intercourse with subsequent risk of
pregnancy
20
Sexual assault
1,3
All of the above
56
None of the above
6,7
14-17
18,7
18-30
76
12. Within how many hours after intercourse should the
morning-after pill be prescribed:
31-40
2,7
12-24
9,3
48
24
72
62,7
41-50
Unknown
1,3
5. Woman’s na tionality
120
4
Italian
97,2
Don’t know
0
Foreign
2,8
13. Within how many hours after sexual intercourse does
the morning-after pill lose the most of its effectiveness:
AREA 4: Characteristics of management of pregnancy of
women requesting EC prescription
6. Civil status
Single, not cohabiting with partner
18
7. Parousness
60
Cohabiting with partner
Married
1,3
Unknown
36
12-24
17,3
48
21,3
72
52
120
6,7
Don’t know
2,7
Table 2
AREA 6: Prescriber’s knowledge about the EC pill’s pharmacodynamics
21. When asked to give the morning-after pill, do you
generally:
14. What are the modes of assumption of the morningafter pill:
Prescribe it and give information about regular contraception
70,7
The first pill must be taken at prescription and the second
12 hours later
13,3
Prescribe it but do not give information about regular
contraception
18,7
Both pills should be taken concurrently at prescription
52
33,4
Refuse to give it and refer the woman to a gynecologist
instead
4
Both of the above
Don’t know
1,3
Refuse to give it and inform the woman that it would give
conscientious objection
2,7
Not usually, but it can cause nausea, vomiting and headache
in some cases
96
AREA 8: Role of the prescriber in the emergency department
Yes, severe metrorrhagia
2,7
22. When asked to give the morning-after pill:
Yes, fetal malformations if contraception ineffective
0
It should always be provided
57,3
1,3
It may be offered in some circumstances or give conscientious objection on the basis of the deontological code
25,3
It may be offered in some circumstances or give conscientious objection on the basis of Law 194/78
13,3
Yes, other effects
16. Diagnostic determinations must be performed before
prescribing the pill:
No
80
Yes, blood coagulation test
2,7
Yes, pregnancy test
16
23. Has it ever happened that one or more women arrived for care at the emergency department where you
work and asked for the morning-after pill because they
had been refused at another medical facility:
Yes, for other reasons
Yes
65,8
17. What is the mechanism of action of the morning-after
pill:
No
34,2
Inhibits ovulation, like other oral contraceptives
17,3
24. If yes, what type of health care provider did they usually seek before coming to your department:
Through a complex mechanism of action involving inhibition of ovulation and fecundation, alteration of tubal ciliar
motility and sperm motility, inhibition of implantation of
embryo
70,7
Another emergency department
23,2
A physician on out of hours service
47,8
Through an abortive mechanism like that of RU486
6,7
A family-planning service
4,3
A general practitioner
11,7
Unknown
13
18. Use of the morning-after pill can lead to:
An increase in risky sexual behavior and STIs
11
An increased risk of no longer using regular contraception
20,6
A decrease in unwanted pregnancies
25,8
A decrease in elective abortions
27,1
Greater self-determination for women
7,7
None of the above
7,7
*the% of respondents take into account the missing
Very uncomfortable
21,3
age and main reason for requesting the EC pill (p=0.0001) and between civil status and reason for requesting the EC pill (p=0.0001).
Sex, age and emergency department level did not affect the pharmacodynamics knowledge of the physicians interviewed (Table 4).Sex
was associated with correct knowledge of the time within which EC
can be administered in univariate analysis but not in multivariate
analysis. A statistically significant effect was noted between the ED’s
level and the knowledge of the time window within which the drug
needs to be taken in order to be most effective (Table 4).
A statistically significant effect (p=0.003) was noted between emergency department level and peak months but not peak days for
EC requests (p=0.56); a statistically significant effect was also seen
between emergency department level and reported woman’s civil
status (p=0.001), history of previous voluntary abortion (p=0.004)
and request for the EC pill (p=0.001), whereas no statistically significant effect was noted for the number of requests made (p=0.93).
Slightly uncomfortable
24
Discussion
Fairly comfortable
26,7
Very comfortable
5,3
Absolutely comfortable
21,3
The strengths of this survey are that it was conducted from the
perspective of emergency medical staff (10,12) rather than that
of women arriving for care at the casualty department (1-3); involved emergency departments in secular hospitals; analyzed re-
AREA 7: Prescriber’s behavior/attitudes
19. Do you feel that dispensing EC is appropriate for an
emergency department:
Yes
52
No
48
20. How comfortable do you feel about dispensing the
morning-after pill:
15. Does the morning-after pill cause major side effects:
19
Table 3.
Bibliographic references for questionnaire items.
20
Study
Questionnaire item
Gbolade BA, Elstein M,Yates D. UKÊ accidentÊ andÊ
emergencyÊ departmentsÊ andÊ emergencyÊ contraception:Ê whatÊ doÊ theyÊ thinkÊ andÊ do? J Accid Emerg Med.
1999 Jan;16(1):35-8.
1, 19, 21
Golden NH, Seigel WM, Fisher M, Schneider M,
Quijano E, Suss A, Bergeson R, Seitz M, Saunders D. EmergencyÊ contraception:Ê pediatriciansÕ Ê
knowledge,Ê attitudes,Ê andÊ opinions. Pediatrics. 2001
Feb;107(2):287-92.
1, 10, 12,
13,15, 16,
18, 20
Millar JR, Leach DS, Maclean AV, Kovacs GT.
TheÊ useÊ ofÊ emergencyÊ contraceptionÊ inÊ AustralasianÊ emergencyÊ departments. Emerg Med. 2001
Sep;13(3):314-8.
12, 14, 21
Bastianelli C, Farris M, Benagiano G. ReasonsÊ forÊ
requestingÊ emergencyÊ contraception:Ê aÊ surveyÊ ofÊ 506Ê
ItalianÊ women. Eur J Contracept Reprod Health
Care. 2005 Sep;10(3):157-63.
9, 10, 18, 23,
24
quests for EC from women of reproductive age (14-50 years old)
rather than being limited to either the over-18 years of age population, as in studies by Kosunen (2), Aneblom (3), and Olszewski
(7), or adolescents (<18 years of age)(6).
Analysis of survey responses show that the largest age group
comprised women aged 18-30 years old (76%), similar to findings by Kosunen (70.8%) (2), Bastianelli (87.1%) (1), and Aneblom (88.9%) (3), followed by adolescent girls (14-17 years old)
(18.7%), unlike Bastianelli (1) who reported the over-30 years of
age group as second largest group (8.9%). In line with Kosunen’s
observations (50%) (2), in physicians’opinion most women were
single and not cohabiting with a partner (60.0%), but unlike
those of Aneblom (3), nulliparous (64.0%). The vast majority of
women were described as Italian nationals (97.2%).
Except for the frequency of requests from adolescents, our survey
results are substantially similar to those reported by other studies. Our results differ in that they reflect the perceptions of medical staff with regard to EC prescription, and as such, might have
been influenced by an insight bias. In this connection, it would
be interesting to compare our findings with survey samples of
women residing in the same area. Another aspect to emerge from
our study was the overwhelming preponderance of Italian nationals, from which it could be inferred that non-Italian nationals are
either unaware of the morning-after pill or encounter barriers to
access to EC. This question merits further study.
Interviewed physicians stated that most cases of women arriving
for care were first-time requests for EC, as previously reported
by Checa (93%) (4) and Bastianelli (93%) (1), and motivated by
condom breakage or slippage, as found by Vergara Cano (91%)
(5) and Bastianelli (64%) (1).
Unlike the data Checa (4) reported in their 9-year epidemiological study describing a net seasonal peak of EC requests during the
summer months, we observed no seasonal trends; instead, weekend peaks were noted, in line with observations by Checa (4) and
other reports (3,4,7). In contrast, emergency department level appeared to influence the seasonal but not the weekly distribution
of request frequency.
In general, our results show that neither prescriber sex nor age
had an effect on knowledge of the EC pill’s pharmacokinetics or
pharmacodynamics, whereas emergency department level did.
Specifically, physicians working in a level I emergency department were more knowledgeable about the reduction time of the
EC’s effectiveness, which did not appear to be correlated to familiarity with prescribing it, given the lack of a statistically signifi-
cant difference in the frequency of requests between level I and
level II emergency departments.
Regarding knowledge about the pill’s pharmacokinetics, most
emergency physicians responded correctly to the items investigating reasons and time window for prescription; most did not
limit its prescription to particular circumstances (e.g., sexual assault, risk of current pregnancy); but, again, most stated that the
pill had to be given within the first 72 hours after intercourse to
be effective. Indeed, the question of its effective time limit (72 vs.
120 hours postcoitus) remains controversial. EC products commercially available in Italy carry the indication for use within 72
hours after unprotected intercourse, but the WHO recommends
prescribing EC within 120 hours postcoitus (14). According to a
recent systematic literature review (13), no significant reduction
in effectiveness was observed when levonorgestrel was administered within 72 versus 120 hours after unprotected intercourse.
That is discussed as the option of prescribing ulipristal acetate
for EC requested more than 72 hours after intercourse (15-17).
As regards prescriber’s knowledge about the pill’s pharmacodynamics, the responses often differed from those expected. Many physicians stated that the first pill should be taken at prescription and the
second within 12 hours, whereas the WHO recommends taking both
pills contemporaneously. Currently, there is no scientific evidence
that concomitant administration can significantly diminish the pill’s
effectiveness; instead, the underlying reason is that in this way the
risk of forgetting to take the second pill is averted and consequently
the potential failure to reach the recommended dose (13,14).
While many physicians stated that EC use could lead to an increase in risky sexual behavior and STIs, this belief has never been
corroborated by published data.
Also intriguing was the widely held notion that EC pills have a
complex mechanism of action rather than acting through simple
inhibition of ovulation. Research conducted to date has demostrated that the pills inhibit ovulation, but the role of the other mechanisms of action remain controversial (18-20) which is perhaps why
the responses given in our study differed from those expected.
In line with previously published data on the frequency distribution of requests for EC, our survey results show that requests were
most frequent at the weekend, when continuity of care is provided
only by physicians on out of hours service and by emergency departments. Unlike other reports (1), our survey found that the ED was
the first point of care in only 34.2% of cases. A partial explanation
for this difference could be that women preferred seeking care first
from a physician on out of hours service (47.8%) and, if refused, by
the health provider subsequently turned to a emergency department.
Our data indicate that the majority of emergency physicians
(70.7%) are willing to provide EC, which corresponds to the
percentage of women who reported having been refused the
morning-after pill at another ED. This finding should be viewed
with caution, however; many of the questionnaire respondents
are probably aware of this problem and this might have been a
cause of overestimation. Also, barriers to access to EC could have
been caused by the limits placed on care provided through weekend/holiday work shifts during peak periods and by the 30% of
physicians who refuse to offer EC. Furthermore, although the
ED appears to be a preferred point of care for seeking EC, many
emergency physicians felt uneasy about prescribing EC and did
not consider it an appropriate part of emergency department services. A variety of reasons may underlie this uneasiness with EC
prescription: dispensing EC may not be seen as a real emergency
or urgent medical need requiring the services of an emergency
department; EC prescription may be viewed as a matter for specialists; offering EC may conflict with personal ethos if perceived
as a form of abortion. Indeed, all the physicians who give conscientious objection to EC prescription grounded their claim on
the provisions of Law 194/78 regulating legal voluntary abortion.
They also stated that the pill has a mechanism of action that induces abortion or works through a complex mechanism of action that inhibits implantation of the embryo in the uterus, which
some consider to be morally similar to abortion.
Table 4.
Results of univariate and multivariate analysis on the physicians’ responses with regard to knowledge of pharmacokinetics and
pharmacodynamics of E
Gender (F vs M)
DEA_level (II vs I)
Age
Univariate an.
Multivar. an
Univariate an.
Multivar. an
Univariate an.
Multivar. an
OR (CI 95%)
p-value
OR (CI
95%)
p-value
OR (CI 95%)
p-value
OR (CI
95%)
p-value
p-value
p-value
Prescriber’s knowledge about the EC pill’s pharmacokinetics
Item n. 11 - Correct answer: Unprotected sexual
intercourse in the 120 hours preceding the
request
2.07 (0.32;
13.5)
0.43
Item n. 12 - Correct answer: 72*
2.73 (0.97;
7.7)
0.047
Item n. 13 - Correct answer: 12-24
0.79 (0.23;
2.7)
0.70
2.61 (0.88;
7.7)
0.08
1.29 (0.20;
8.3)
0.79
0.22
0.63 (0.23;
1.7)
0.35
0.86
0.05 (0.005;
0.5)
<0.01
<0.01^
0.40
Item n. 14 - Correct answer: Both pills should be
taken concurrently at prescription*
1.29 (0.51;
3.3)
0.59
0.88 (0.34;
2.3)
0.79
0.78
Item n. 15 - Correct answer: Not usually, but it
can cause nausea, vomiting and headache in some
cases
0.11 (0.01;
2.4)
0.08
0.58 (0.05;
6.8)
0.66
0.33
Item n. 16 - Correct answer: No
1.52 (0.45;
5.1)
0.50
1.29 (0.39;
4.2)
0.67
0.96
Item n. 17 - Correct answer: Inhibits ovulation, like
other oral contraceptives
1.60 (0.47;
5.5)
0.44
0.86 (0.24;
3.0)
0.82
0.16
* UNDP, UNFPA, WHO, World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP). Fact
sheet on the safety of levonorgestrel-alone emergency contraceptive pills (LNG ECPs)
^ ED of level II predicts perfect failure (no correct answers)
References
1.
Bastianelli C, Farris M, Benagiano G. Reasons for requesting emergency
contraception: a survey of 506 Italian women. Eur J Contracept Reprod
Health Care. 2005 Sep;10(3):157-63.
2. Kosunen E, Sihvo S, Hemminki E. Knowledge and use of hormonal emergency contraception in Finland. Contraception. 1997 Mar;55(3):153-7.
3. Aneblom G, Larsson M, von Essen L, Tydén T. Women’s voices about
emergency contraceptive pills “over-the-counter”: a Swedish perspective.
Contraception. 2002 Nov;66(5):339-43.
4. Checa MA, Pascual J, Robles A, Carreras R. Trends in the use of emergency contraception: an epidemiological study in Barcelona, Spain (19942002). Contraception. 2004 Sep;70(3):199-201.
5. Vergara Cano JC, López-Guerrero Almansa A, López López F. Anticoncepción de emergencia: perfil de la usuaria en servicios de urgencias de
atención primaria. Aten Primaria. 2004 Oct 15;34(6):279-82.
6. Falah-Hassani K, Kosunen E, Shiri R, Rimpelä A. Emergency contraception among Finnish adolescents: awareness, use and the effect of nonprescription status. BMC Public Health. 2007 Aug 9;7:201.
7. Olszewski J, Olszewska H, Abacjew A, Chmylko L, GaworskaKrzeminska A. The use of emergency contraception in young Polish women. Acta Obstet Gynecol Scand. 2007;86(7):861-9.
8. Douglass M. Emergency contraception in the ED. J Emerg Nurs. 2007
Apr;33(2):140-2.
9. Gbolade BA, Elstein M, Yates D. UK accident and emergency departments and emergency contraception: what do they think and do? J Accid
Emerg Med. 1999 Jan;16(1):35-8.
10. Rosenberg KD, Demunter JK, Liu J. Emergency contraception in
emergency departments in Oregon, 2003. Am J Public Health. 2005
Aug;95(8):1453-7. Epub 2005 Jun 28.
11. Espey E, Ogburn T, Leeman L, Buchen E, Angeli E, Qualls C. Compli-
12.
13.
14.
15.
16.
17.
18.
19.
20.
ance with mandated emergency contraception in New Mexico emergency
departments. J Womens Health (Larchmt). 2009 May;18(5):619-23.
Harrison T. Availability of emergency contraception: a survey of hospital
emergency department staff. Ann Emerg Med. 2005 Aug;46(2):105-10.
Cheng L, Gülmezoglu AM, Piaggio G, Ezcurra E, Van Look PF. Interventions for emergency contraception. Cochrane Database Syst Rev.
2008 Apr 16;(2):CD001324.
UNDP, UNFPA, WHO, World Bank Special Programme of Research,
Development and Research Training in Human Reproduction (HRP).
Fact sheet on the safety of levonorgestrel-alone emergency contraceptive
pills (LNG ECPs). [last access 30 oct 2010] Downloaded by http://
www.who.int/reproductivehealth/publications/family_planning/
HRP_RHR_10_06/en/
Glasier AF, Cameron ST, Fine PM, Logan SJ, Casale W, Van Horn J et
al. Ulipristal acetate versus levonorgestrel for emergency contraception:
a randomised non-inferiority trial and meta-analysis. Lancet. 2010 Feb
13;375(9714):555-62.
Page GH, Verhaeghe V. Ulipristal acetate for emergency contraception?
Lancet. 2010 May 8;375(9726):1608
Piaggio G, von Hertzen H. Ulipristal acetate for emergency contraception? Lancet. 2010 May 8;375(9726):1607-8
Croxatto HB, Devoto L, Durand M, Ezcurra E, Larrea F, Nagle C,
et al. Mechanism of action of hormonal preparations used for emergency contraception: a review of the literature. Contraception. 2001
Mar;63(3):111-21.
Gemzell-Danielsson K, Marions L. Mechanisms of action of mifepristone
and levonorgestrel when used for emergency contraception. Hum Reprod
Update. 2004 Jul-Aug;10(4):341-8. Epub 2004 Jun 10. Review.
Novikova N, Weisberg E, Stanczyk FZ, Croxatto HB, Fraser IS. Effectiveness of levonorgestrel emergency contraception given before or after
ovulation--a pilot study. Contraception. 2007 Feb;75(2):112-8.
Prescriber’s knowledge about the EC pill’s pharmacodynamics
21
proceedings
I Congresso Nazionale Great Italia, Roma 19-21 ottobre 2010
Ems personnel and post-traumatic stress disorder (ptsd):
a case report
°Alberto Gabrieli, °Marco Calzoni, *Costantino Caroselli, °Vittorio Schweiger, °Enrico Polati
°Scuola di Specializzazione in Anestesia, Rianimazione e Terapia Intensiva, Azienda Ospedaliera Universitaria Integrata, Ospedale Policlinico
Verona; *Dipartimento di Emergenza ed Accettazione, Azienda Ospedaliera Universitaria Integrata, Ospedale Civile Maggiore, Verona
Learning Objective
We discuss a clinical case of serious emotional impact in prehospital setting. We use this case to update our knowledge and
to understand the underestimated Post-Traumatic Stress Disorder
(PTSD) risk among the EMS personnel.
Case Report
The prehospital medical team was sent for an imminent delivery.
An ambulance with ED nurse and 2 EMTs was already on scene.
On quick-look the patient was suffering, sweated, screaming and
rolling about in pain on bed. She was at end-term pregnancy (38
weeks). The abdomen was an end-term one, with no movement
palpable and no trauma signs. Membrane’s rupture was recorded
at fastcar arrival. The clinical exam showed a cervix dilatation
of approximately 2 centimeters. So we decided to evacuate the
patient to the nearest hospital for a safe delivery and to prepare
ourselves for an emergency delivery in ambulance. During
ambulance run the patient started to feel periodic contractions.
An on-route evaluation showed an approximately 8 centimeters
cervix dilatation with the vertex appearance. During ambulance
parking a violent contraction produced the vertex exit with a
very abundant hemorrhage. Then the patient screamed and kept
pressing hardly her baby vertex. She was promptly immobilized
and transferred in the emergency room where an OB/GYN and
neonatologist teams was expecting us. Immediately on the
ambulance stretcher the team performed a urgent episiotomy
with a very abundant blood and meconium discharge. We assisted
the delivery of dead baby which at a first look seemed to be dead
days before, probably because of a skull malformation. After that
the ambulance crew communicated the inoperative status for
non specified hygienic reason for all the day-shift. The same crew
didn’t want to complete the debriefing the subsequent days. The
ED-nurse went on sick leave for a while and after one month she
was transferred to another ward in another hospital.
Discussion
Post-Traumatic Stress Disorder (PTSD) is a anxiety disorder that
may occur after a psychological trauma exposure. The frequency
and the severity of PTSD seem to be related to the proximity to
the trauma. Another important factor is the chronic and repeated
exposure to stress events, as might happen among rescue and
emergency personnel. EMS personnel are constantly exposed
to traumatic psychological stress due to the repeated daily high
exposure to human suffering and death and working in hazardous
environment. Estimates of prevalence of PTSD in this group have
been around 20% [1]. PTSD should be diagnosed if full criteria
for PTSD as defined by the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-R) are met. Subclinical PTSD can be
defined as satisfying re-experiencing category and either avoidance
category or hyperarousal one, but not both [2]. Biological studies
have demonstrated that patients with PTSD have increased
circulating levels of norepinephrine, increased reactivity of alfa2adrenergic receptors and increased thyroid hormone levels.
There are also evidences on neuroanatomical alterations in brain
areas involved in fear response. Besides, cognitive problems and
some intrusive recollections that characterize PTSD can have a
neuroanatomical substrate in hippocampal alterations [3]. The
PTSD treatment is based on providing disease knowledge and
support. This is the base to build some sort of therapeutic alliance
and to emphasize that patients are not alone. Critical Incident
Stress Debriefing (CISD) is “a structured intervention designed
to promote the emotional processing of traumatic events through
the ventilation and normalisation of reactions and preparation
for possible future experiences.” Medications such as Sertraline
and Paroxetine may also benefit traumatized patients [4]. A key
imperative for any Emergency Medical Service is to develop
strategies for both the prevention and treatment of the significant
levels of mental health problems associated with emergency
work. In the EMS there is a high underestimated risk of PTSD,
but the most important strategy is to create a risk surveillance
system about the psychological aspects of this job and to build-up
the base of treatment starting with debriefing and defusing.
References
1. Clohessy S, Ehlers A (1999) PTSD symptoms, response
to intrusive memories and coping in ambulance service
workers. Br J Clin Psychol 38:251–265.
2. Mishra S, Goebert D, Char E et al (2010) Trauma exposure
and symptoms of post-traumatic stress disorder in emergency
medical services personnel in Hawaii. Emerg Med J published
online May 13.
3. Hamner MB, Lorberbaum JP, George MS (1999) Potential
role of the anterior cingulate cortex in PTSD: Review and
hypothesis. Depression and Anxiety 9 (1): 1–14.
4. Smith A, Roberts K (2003) Interventions for post-traumatic
stress disorder and psychological distress in emergency
ambulance personnel: a review of the literature. Emerg Med
J 20: 75-78.
22
Atorvastatina vs anacetrapib nel controllo del
Tromboembolismo Venoso In Pazienti Oncologici
proceedings
R. Di Filippo¹, A. Melone², E. Varrato³, S. Sofia4, C. Balsano*
Nella popolazione generale l’incidenza annuale di eventi tromboembolici (TEV) è di 117 casi ogni 100.000 abitanti. La presenza di
una neoplasia aumenta di circa quattro volte tale rischio, mentre
nei pazienti che ricevono la chemioterapia il rischio è aumentato
di circa sette volte. Le cellule tumorali possono attivare il sistema
coagulativo attraverso meccanismi indiretti, determinando l’attivazione di cellule ematiche quali i monociti, le piastrine e le cellule
endoteliali ed inducendo, in questo modo, l’espressione di un fenotipo procoagulante. Infatti, piastrine e cellule endoteliali entrano comunemente a far parte dell’avvio della cascata coagulativa e
sono inoltre suscettibili di attivazione da parte delle citochine (IL1; VEGF; TNF-alfaetc.), anch’esse prodotte dalle cellule tumorali.
Il trattamento standard del TEV in pazienti con cancro, in assenza
di controindicazioni note, non differisce da quello dei pazienti non
affetti da neoplasia (somministrazione di eparina a basso peso molecolare, ENF o EBPM, seguita dall’anticoagulazione con anticoagulanti orali).
I pazienti neoplastici con TEV, durante il trattamento anticoagulante orale, sono esposti ad un rischio significativo sia di recidive
trombotiche che di complicanze emorragiche, rispetto ai pazienti
non neoplastici. Da quanto detto si evince come la condotta terapeutica da far seguire a questi pazienti debba tener conto sia
dell’elevato rischio di recidiva, che del rischio emorragico. Infatti, nonostante un’adeguata anticoagulazione circa il 5-7% dei
pazienti con cancro sviluppa una recidiva di TEV. Nonostante i
dati incoraggianti mostrati dall’uso delle statine nei pazienti oncologici, il loro uso spesso è associato ad un ben noto incremento
dose-dipendente delle transaminasi; quindi si tratta di farmaci di
difficile utilizzo nei pazienti sottoposti a chemioterapia e sono
assolutamente sconsigliati nei pazienti con insufficienza epatica
o con epatocarcinoma.
Recentemente, è stata messa in luce l’efficacia degli inibitori della
Proteina di Trasferimento degli Esteri del Colesterolo (CETP), in
particolare dell’Anacetrapid, nell’aumentare i livelli di colesterolo
HDL. Nei pazienti oncologici sottoposti a regime chemioterapico
la somministrazione di inibitori delle CETP potrebbe determinare una migliore prevenzione e/o ridurre l’incidenza di rischio
di TEV rispetto ai pazienti sottoposti a regime chemioterapico
trattati con statine (Atorvastatina).
Il nostro gruppo vuole, quindi, valutare la possibilità di trattamenti di combinazione con chemioterapici e ipolipemizzanti in
modo da ottenere trattamenti più efficaci per la terapia a lungo
termine del TEV in pazienti con patologia neoplastica.
Verrà pertanto effettuato uno studio randomizzato su due gruppi
omogenei di pazienti sottoposti a regime chemioterapico, a cui
verrà associato Atorvastatina o Anacetrapib per osservare gli effetti sull’incidenza di TEV e sul rischio emorragico.
Bibliografia
1. Silverstein MD, Heit JA, Mohr DN, et al. Trends in the incidence of deep vein thrombosis and pulmonary em bo-lism: a
25-year population-based study. Arch Intern Med 1998; 158:
585-93.
2. Dvorak HF. Abnormalities of hemostasis in malign ant disease. In: Colman RW, Hirsh J, Marder VJ, Saltzman EW,eds. Hemostasis and thrombosis: basic principles and clinical practi
ce. Philadelphia: Lippincott 1994; 1238-54.
3. Falanga A., Donati M.B. Pathogenesis of thrombosis in patients with malignancy. Int J of Hematol 2001; 73: 137-144.
4. DevarajS,ChanE,JialalI,etal.Directdemonstrationofantiinflammatoryeffectofsimvastatininsubjectswit hthemetabolic
syndrome. JClinEndocrinolMetab.2006;91:4489-4496.
5. Ray JG, Mamdani M,Tsuyuki RT, et al. Use of tatins and the
subsequent development o deep vein thrombosis. Arch Intern Med. 2001;161:1405-1410.
6. Caine GJ, Stonelake PS, Lip GY, et al. The hypercoagulable
state of malignancy: pathogenesis and current debate. Neoplasia. 2002;4:465- 473.
Biomarkers And Fever in the Emergency Department:
BAFED study
V. Mura*, B. De Berardinis*, F. Travaglino*, E. Salvatori*, CS. Gori*, C. Bongiovanni*, V. Russo*, O. Piras*,
G.Salerno**, M. Candelli***, N. Gentiloni Silveri***, P.Cardelli**, S. Di Somma*.
*Emergency department Azienda Ospedaliera Sant’Andrea, II School of Medicine “La Sapienza” University, Rome, Italy;
** Clinical and molecular medicine department Azienda Ospedaliera Sant’Andrea, II School of Medicine “La Sapienza” University, Rome, Italy;
*** Emergency department Policlinico A. Gemelli, Catholic University of the Sacred Heart, Rome - Italy
Introduzione
La pro-calcitonina (PCT) e la pro-adrenomedullina (Mid-Regional proAdrenomedullin – MR pro-ADM) sono tra quei peptidi le cui concentrazioni plasmatiche subiscono incrementi di rilievo nelle infezioni batteriche. Obiettivo del nostro studio è stato quello di valutare all’arrivo
del paziente in PS per febbre, con o senza dispnea: i livelli di Procalcitonina e di MR proADM, la correlazione tra APACHE II score e PCT, la
correlazione tra APACHE II score e MR proADM, al fine di vedere se i
livelli dei suddetti biomarkers possono essere correlati in modo lineare
con uno score complesso e “multiparametrico” come l’APACHE II.
Materiali e metodi
Studio no profit, osservazionale, multicentrico.
Sono stati arruolati, in maniera competitiva, 98 pazienti con febbre, con o senza dispnea, ammessi in Pronto Soccorso nel periodo
compreso tra Settembre 2009 e Settembre 2010.
¹U.O. di Medicina Interna, P.O. “S. Salvatore” dell’Aquila;
²U.O.C. di Medicina e Chirurgia D’urgenza e Accettazione, P.O. “S.S. Filippo e Nicola” di Avezzano;
³U.O. di Medicina Interna, P.O. “G. Mazzini” di Teramo;
4
U.O. di Medicina Interna, P.O. “Santissima Maria dello Splendore” di Giulianova;
*Dipartimento di Medicina Interna e Sanità Pubblica, Università degli studi dell’Aquila
23
proceedings
All’arrivo dei pazienti in PS sono stati eseguiti: anamnesi ed esame
obiettivo (compreso Glasgow Coma Scale), EGA, prelievo per chimica clinica, emocromo, PCT e MR pro-ADM, APACHE II score.
Il dosaggio della PCT e dell’MR pro-ADM sono stati effettuati utilizzando il Kriptor (Brahms).
Risultati
Sono stati arruolati 98 pazienti. I risultati hanno dimostrato valori medi di PCT 4.05 ng/ml e di MR pro-ADM 1.99 nmol/l. La
correlazione tra APACHE II score e PCT è risultata statisticamente significativa (p<0,001), ugualmente significativa è risultata la
correlazione tra APACHE II e MR pro-ADM (p<0.001) e tra PCT
e MR pro-ADM (p< 0.001).
Conclusioni
Nei pazienti con febbre i valori della PCT e dell’MR pro-ADM assumono un significato prognostico nella valutazione del paziente
con febbre in Pronto Soccorso.
Le variazioni meteorologiche a breve termine come fattore
di rischio per colica renale: analisi su 8168 coliche renali
rilevate in sette anni di attività del Pronto Soccorso di Parma
Ivan Comelli
Scuola di Specializzazione in Medicina in Emergenza-Urgenza, Università degli Studi di Parma
24
La patogenesi della formazione dei calcoli renali è un processo
complesso, ampiamente variabile in base alla composizione chimica dei calcoli stessi. È inoltre documentata una ampia variabilità geografica, in gran parte attribuibile alla temperatura media
annuale (Mean Annual Temperature, MAT) delle diverse aree, ed
una variabilità stagionale non altrettanto compiutamente documentata. La prevalenza di nefrolitiasi è stimata intorno al’1-6,6%
a livello mondiale; la suddetta variabilità geografica si esplicita
sinteticamente come segue: 1-5% in Asia, 20% in Arabia Saudita,
13% in Nord America, 5-9% in Europa; in Italia si aggira intorno
al 10 %. Alcuni ricercatori hanno riportato un aumento di visite
in Pronto Soccorso per colica renale durante l’estate, ma non è
chiaro il nesso tra variazione meteorologica e insorgenza della
colica, in considerazione del fatto che la formazione del calcolo è
un processo lento, che dura diverse settimane (alcuni ricercatori
hanno riportato una latenza media di 90 giorni tra il trasferimento in aree caratterizzate da caldo intenso e secco e formazione dei
calcoli). In base ai suddetti dati, l’autore si è proposto con questo
studio di valutare l’influenza delle variazioni meteorologiche rilevate su base giornaliera sul numero di visite per coliche renali nel
Pronto Soccorso dell’Azienda Ospedaliero-Universitaria di Parma
(bacino d’utenza provinciale, in area caratterizzata da clima continentale temperato). Sono stati estratti i dati dal database informatico del nostro Pronto Soccorso, utilizzando una doppia chiave
di ricerca (codice ICD-9: 7880, e “stringhe” verbali estratte dalla
diagnosi descrittiva di dimissione). Con tale metodologia sono
stati identificati, nel corso del periodo di 2557 giorni presi in considerazione (1° gennaio 2002 – 31 dicembre 2008), 8168 episo-
di di colica renale. Il numero totale di accessi al PS nello stesso
periodo è stato di 557990, risultandone una percentuale pari a
1.46% delle visite per colica renale, dato in linea con altri report
di letteratura. Il numero di coliche per giorno, e la temperatura
media giornaliera di ogni singola giornata (fornitaci dall’Agenzia
Regionale Per l’Ambiente, ARPA) sono stati sottoposti ad analisi
di regressione lineare, dimostrando una correlazione molto significativa (R = 0.88; p<0.0001). In sintesi, tra pieno inverno (T°
prossime allo 0) e piena estate (T° prossime ai 30 °C) il numero
di accessi medio giornaliero per colica renale aumenta del 47%.
Successivamente è stata eseguita una analisi di regressione lineare
multipla univariata tra ogni singolo episodio di colica e la temperatura media di ogni singola giornata dei trenta giorni precedenti
l’episodio clinico; per tale analisi è stato utilizzato il programma
Mathematica 7 ®. Sono state dimostrate analoghe significative
correlazioni, particolarmente forti nel giorni compresi tra il 5°
e il 7° precedenti l’episodio clinico (R = 0.80; p<0.0001 per il 6°
giorno precedente l’episodio), ma ancora altamente significative
per il 14° giorno (R = 0.77; p<0.0001) ed il 20° giorno (R = 0.70;
p<0.0001) precedenti la colica. I nostri dati suggeriscono l’esistenza di un processo “accelerativo” della formazione del calcolo
che, nel contesto di un processo già avviato, porti alla rapida crescita del calcolo e quindi all’episodio clinico. La disidratazione
e la conseguente concentrazione urinaria sono certamente fattori determinanti, ma si considera anche l’importanza di fattori
dietetici quale l’aumentato consumo di frutta, e quindi di acido
ascorbico (noto acceleratore della precipitazione dei cristalli di
ossalato di calcio), durante i mesi estivi.
Endothelin-1 and nt-probnp levels in acute decompensated
heart failure
Tommaso Barreca 1, Ombretta Cutuli1-2, Stella Ingrassia1-2, Marco Greco1-2, Federico Catalani 1-2, Paolo Moscatelli2
1
Scuola di Specializzazione in Medicina d’Emergenza-Urgenza,Università degli Studi di Genova; 2 U.O.C Pronto Soccorso e Medicina
D’Urgenza, A.O.U. San Martino, Genova
Endothelin-1 (ET-1) is a 21 aminoacids vasoconstrictive peptide, producted by the endothelium and by myocardiocytes. NTproBNP is BNP aminoterminal portion, which is producted by
myocardium in response to myocardiocyte stretching. It causes
natriuresis, vasodilatation and inibition of the RAAS. ET-1 and
NT-proBNP could play an important role in the evolution of acute
decompensated heart failure (ADHF); however there aren’t studies that evaluated their levels in order to find a possible correlation between them and to define their physiopathological role.
Objective
With this study we determined ET-1 and NT-proBNP levels in a
cohort of patiens evaluated in our ED for ADHF to find a possible correlation between the two biomarkers, between each biomarker and haemodynamic parameters and if ET-1 could have
a negative prognostic value in ADHF in a short period (7 days).
Methods
We studied 22 patients, evaluated in our ED with symptoms of
ADHF. NYHA class was II for 2 patients, III for 13 patients, IV for
7 patients. Among them, 18 patients recovered, 4 died in the first
week after admission. Control group was made up of 22 healthy
people of the same age.
At admission we got blood samples to determine ET-1 and NT-proB-
Results
Levels of NT-proBNP and ET-1 was significantly higher (p<0,01)
in patients with ADHF than control group (ET-1: 30,9 ± 16,9
pmol/l vs 2,8 ± 0,67 pmol/l; NT-proBNP: 9696 ± 10326 ng/l vs 743
± 787,1 ng/l). We divided patients into 2 groups according to the
outcome: ET-1 and NT-proBNP levels were significantly higher
(p<0,01) in deceased patients than in those who survived (ET-1:
46,1 ± 18,6 pmol/l vs 27,5 ± 15,1 pmol/l; NT-proBNP: 20468 ±
14718 ng/l vs 7300,9 ± 7751,2 ng/l). Linear regression showed
a statistically significant correlation (p<0,01) between ET-1 and
NT-proBNP levels. We didn’t find any correlation between each
biomarker and the other haemodynamic parameters (MAP, HR,
SO2, NYHA class) that we have evaluated, except for heart rate
(HR) and ET-1 (p<0,01).
Multiple linear regression showed that indipendent variables ET1, NT-proBNP, HR, mean arterial pressure (MAP), but not sex,
age, NYHA class and oxygen saturation, negatively influence the
dependent variable outcome.
Discussion
Our results show that ET-1 and NT-proBNP increase simultaneously in ADHF and they correlate between them. The physiopathological mechanism at the basis of this, how it’s been demonstrated by in vitro and in vivo studies, could be multifactorial.
Different factors could induce release of the two biomarkers, as
myocardiocyte stretching, hypoxia, pulmonary congestion; each
hormone could influence the release of the other one, but the
exact mechanism are still not known.
Our study shows that ET-1 could have a good prognostic value
in ADHF outcome and suggests a possible co-secretion of ET-1
and NT-proBNP.
Pulmonary embolism risk stratification in prehospital care:
is there a rule?
°Alberto Gabrieli, °Marco Calzoni, °Vittorio Schweiger, °Enrico Polati
°Scuola di Specializzazione in Anestesia, Rianimazione e Terapia Intensiva, Azienda Ospedaliera Universitaria Integrata, Ospedale Policlinico
Verona
Learning Objective
We discuss a clinical high-suspected Pulmonary Embolism
diagnosis in pre-hospital setting. We use this case to update our
knowledge on this disease, to understand what could help us in
pre-hospital setting to choose the right level of suspect and so the
correct hospitalization.
Case Report
The prehospital medical team (Fast-Car) was sent for acute
dyspnea in a rural land field used as a truck parking. A patient
quick look show us a young man (30 years old) with high
respiration rate (30/min). The patient was conscious, alert,
free airway. We put oxygen with tape around the face mask to
seal it and to avoid dust inhalation. Chest observation showed
normal thorax expansion, murmur generally diminish without
pathological sounds; the oxygen blood saturation was recorder
of 87% in O2. Blood pressure was 100/70 with regular heart rate
of 150 bpm. A 12-lead ECG showed a wide QRS and a righ-shift
of QRS axis, compatible with RBBB. We put 2 large-bore venous
catheter and start crystalloid infusion. The GCS was 14 (E:3, M;6,
V:5) and destrostick was 110 mg/dL. The patient Exposure showed
us a very suffering patient, moderate jugular distension, midline
trachea. The lower limb exposition showed us an asymmetry on
leg diameters: the left one was hard on touch, painful, swelling,
with a positive Homan sign. The patient was a Bulgarian truck
driver. He refer the dyspnea acute onset after a 2 day driving work.
He denied chest pain. Then, we calculated the Well Criteria for the
Pulmonary Embolism (PE). The result was recorded as 7.5/12.5
consequently the patients was identify in high risk level group.
When the transport ambulance arrived, we choose the far hospital
(35 km) because the close ones didn’t have personnel and resources
to manage this pathology. After 28 minutes we arrived in the
Emergency Department where a pre-alerted emergency team with
cardiologist support waiting us. The patient undergo promptly to
a full emathochimic and cloathing screen, arterial blood sample,
12-lead-ECG, Emergency Echocardiography, and the CT Scan.
The patient was admitted to ICU and he was discharge after 3
weeks in good conditions with the definitive diagnosis of Bilateral
Pulmonary Embolism due to Left Deep Venous Thrombosis (DVT).
Discussion
Pulmonary embolism (PE) is a relatively common cardiovascular
emergency. PE and DVT are two clinical presentations of venous
thromboembolism (VTE) and share the same predisposing factors.
In most cases, in fact, PE is a consequence of DVT. PE is a difficult
diagnosis that may be missed because of non-specific clinical
presentation (1). Despite the limited sensitivity and specificity of
signs and symptoms, the combination of these variables by the use
of a prediction rule, makes it possible to discriminate suspected
PE patients in categories of clinical probability corresponding to
an increasing prevalence of PE. The most frequently used clinical
prediction rule is the Canadian rule, by Wells et al. (2). This
rule has been validated extensively using both a three-category
(low, moderate or high clinical probability) and a two-category
scheme (PE likely or unlikely). It is simple and based on easily
collected information. However, the reproducibility was found to
be variable due to the weight of one subjective item in the rule
(“alternative diagnosis less likely than PE”) (3).
As for Trauma, Cardiac and Stroke patients categories, we try to
apply a method to transfer the patient with diagnostic suspect
of PE in the hospital that can manage it better. As for EDs we
use a clinical prediction rule to choose the right hospital for
the right patient. We presented only a pilot case while further
prospective projects to define this method on prehospital care
are on the way.
References
1. White RH. The epidemiology of venous thromboembolism.
Circulation 2003; 107(23 Suppl. 1):I4–I8.
2. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon
C, Gent M et al. Derivation of a simple clinical model to
categorize patients probability of pulmonary embolism:
increasing the models utility with the SimpliRED D-dimer.
Thromb Haemost 2000;83:416–420.
3. The Task Force for the Diagnosis and Management of Acute
Pulmonary Embolism of the European Society of Cardiology
(ESC). Guidelines on the diagnosis and management of acute
pulmonary embolism. European Heart Journal (2008) 29,
2276–2315.
NP levels; we also determined Troponin I and Creatinine levels (if
elevated, they would have been exclusion criteria from the study).
ET-1 was dosed through radioimmunological method and NTproBNP through immunoenzymatic one. The statistical analysis
was made with the analysis of variance (ANOVA); to evaluate
correlation among variables we used linear regression test; instead we used multiple linear regression to evaluate the influence of
ET-1 and NT-proBNP on the patient’s outcome.
proceedings
25
proceedings
B-type natriuretic peptide and acute respiratory failure
°Marco Calzoni, °Alberto Gabrieli, °Vittorio Schweiger, Enrico Polati, °Aldo Luzzani
°Scuola di Specializzazione in Anestesia, Rianimazione e Terapia Intensiva, Azienda Ospedaliera Universitaria Integrata, Ospedale Policlinico Verona
Background
B-type natriuretic peptides (BNP and NT-proBNP) are elevated in
patients with heart failure.
Objective
The aim of this study is to assess the differential diagnostic and
prognostic value of the N-terminal fragment of B-type natriuretic
peptide (NTproBNP) in critically ill adult patients with acute
respiratory failure.
Methods
According to standard
failure in cardiogenic
proBNP measurements
admission. NT-proBNP
mortality.
26
criteria we classified acute respiratory
or noncardiogenic. Patients had NTat admission, at 24 and 48 hours after
was then correlated with diagnosis and
Results
Median values of NT-proBNP (IR 25-75%) were 33364 pg/ml
(4838-35000) in patients with cardiogenic respiratory failure
and 3822 pg/ml (1154-26662) in patients with noncardiogenic
respiratory failure (p<0.05). The area under the ROC curve
(AUC) for cardiogenic respiratory failure was 0.841. At the cut
off value of 3933 pg/ml, NT-proBNP showed a sensitivity of
86.7% and specificity of 76% for the diagnosis of cardiogenic or
noncardiogenic respiratory failure. The trend of NT-proBNP was
not correlated with mortality.
Conclusion
NT-proBNP can discriminate in a statistically significant way
between cardiogenic and noncardiogenic respiratory failure in
critically ill adult patients. Further studies are needed in order to
better define its prognostic value.
References
1. Omland T. Advances in congestive heart failure management
in the intensive care unit: B-type natriuretic peptides in
evaluation of acute heart failure. Crit Care Med 2008;36:17-27.
2. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda
M, Tavazzi L, Smiseth OA, Gavazzi A, Haverich A, Hoes
A, Jaarsma T, Korewicki J, Lévy S, Linde C, Lopez-Sendon
JL, Nieminen MS, Piérard L, Remme WJ. Guidelines for the
diagnosis and treatment of chronic heart failure: executive
summary (update 2005): the task force for the diagnosis and
treatment of chronic heart failure of the european society of
cardiology. Eur Heart J 2005;26:1115-40.
3. Doust JA, Glasziou PP, Pietrzak E, Dobson AJ. A systematic
review of the diagnostic accuracy of natriuretic peptides for
heart failure. Arch Intern Med 2004;164:1978-84.
4. Dieplinger B, Gegenhuber A, Haltmayer M, Mueller T.
Evaluation of novel biomarkers for the diagnosis of acute
destabilised heart failure in patients with shortness of breath.
Heart 2009;95:1508-13.
5. Wang TJ, Larson MG, Levy D, Benjamin EJ, Leip EP, Omland
T, Wolf PA, Vasan RS. Plasma natriuretic peptide levels and
the risk of cardiovascular events and death. N Engl J Med
2004;350:655-63.
BNP and non invasive methodic in the MANAGEMENT of
acute heart failures Verificare inglese molti errori
R. Marino, F. Tocco, A. Giorno,.S. Di Somma
Cattedra E U.O.C. di Medicina d’Urgenza e Pronto Soccorso – Policlinico Sant’Andrea – II Facoltà di Medicina e Chirurgia, Università “La
Sapienza”Roma
Introduction
Nexfin and the techniques of BIVA, actually are used to measure respectively hemodynamic parameters as cardiac index and
hydratation status by non invasive method, rapidly and easily
executable repetitiously. In patients with acute heart failure, because of ventricular stress by volume or pressure overloaded, there is a reduction of cardiac index and an increment of body fluids
that transforming in a status of iperhydratation. Objective of our
study was to validate Nexfin and BIVA techniques to guide together to dosage of BNP, versus diagnosis and intrahospital management by their variations, from admission to discharge of patients
with acute heart failure referring to Emergency department.
Patients and Methods
There are enrolled:44 patients (24 M, 20 F), mean age 77±7,7
(mean±SD) referring to Emergency Department with acute heart
failure. During hospitalization (4,12±1,45, days mean±SD) patients underwent to serial blood samples of BNP, to admission,
o 24 hours, 72 hours and at discharge. In added, at the same
times, Nexfin to evaluate cardiac index and BIVA to evaluate
congestive status were performed contemporarily Patients underwent, according guidelines of American Heart, to diuretic therapy
(120,77±67,15 mg mean±SD) independently of parameters that
examined in the our study during hospitalization.
Results
There was a reduction of BNP with statistically significative difference to 72 hours (357,64±193,81 pg/ml) confirmed
at the discharge (248,57±194,46pg/ml) versus admission
(747,61±658,54 pg/ml) (p<0,005) that joined to a reduction
statistically significative difference at discharge (76,35±5,5 %)
confronting versus admission(79,44±6,47 %) of iperhydratation status. Cardiac index statistically significative way increased confronting with a reduction of BNP and of iperhydratation status at discharge(3,9±1,18L/min/m2)versus admission(2,32±0,95 L/min/m2). There was also a clinical improvement base NYAH class of patients from admission to discharge.
It was highlighted also, in statistically significative difference
a correlation between percentage variation of values cardiac
index and hydratation status from admission to discharge
(R=0,38; p=0,04)
Conclusions
In patients with acute heart failure, in the Emergency department, simultaneous monitoring of cardiac index and of hydra-
tation status by non invasive method is useful to confirm clinical
diagnosis together to BNP value, but moreover intraospital management of patients with acute heart failure. Particularly their
variations can be considerated a valuable help to identify, in easy
and fast way, the improvement of acute heart failure, not only
clically, but even in terms of reduction of congestive status and
increased cardiac performance that needed for the discharge of
patients with acute heart failure from Emergency departments.
proceedings
N1H1 Titolo da definire Titolo da definire Titolo da definire
Titolo da definire Titolo da definire
S. Farina2, L. Zileri Dal Verme1, M. Sabbatini1, D. Marsiliani1, G. Pignataro1, L. Carbone1, M. Candelli1, P. Tilli1, S. Di
Giambenedetto2, N. Gentiloni Silveri1
Dipartimento Emergenza e Accettazione, Università Cattolica del Sacro Cuore - Roma; 2Clinica delle Malattie Infettive, Università Cattolica del
Sacro Cuore - Roma
Introduzione
Nel corso dei primi mesi dell’anno 2009 un nuovo virus influenzale di origine suina, Virus A (H1N1), ha rappresentato un focus rilevante nell’ambito delle patologie infettive emergenti acquisendo in poche settimane le caratteristiche epidemiologiche
di pandemia. Scopo dello studio era valutare l’epidemiologia, la
clinica e le caratteristiche microbiologiche della nuova Influenza
A (H1N1) e di correlare la severità del quadro clinico e eventuali
complicanze con differenti fattori clinici e microbiologici.
Metodi
Tutti i soggetti giunti nei periodi maggio-agosto e settembre-novembre del 2009 presso il Pronto Soccorso del Dipartimento di
Emergenza e Accettazione dell’Università Cattolica del Sacro Cuore di Roma con sintomi respiratori associati a febbre sono stati valutati in uno studio retrospettivo. Di ciascun paziente sono stati
considerati la sintomatologia clinica, le caratteristiche epidemiologiche e i dati di laboratorio. Nell’analisi statistica sono stati inseriti
solo i pazienti con RT-PCR assay positiva per swine-origin influenza A (H1N1) effettuata su materiale respiratorio ottenuto mediante
tampone naso-faringeo. Per l’analisi comparativa tra variabili categoriche è stato utilizzato il test di Fisher’s; per le variabili continue
il T test di Student’s. I fattori significativamente associati a diagnosi
di polmonite sia all’analisi univariata che multivariata sono stati
esaminati mediante regressione logistica. Tutte le analisi statistiche
sono state eseguite mediante SPSS vs. 18.0 (SPSS Inc, Chicago, IL).
Risultati
Sono stati arruolati 104 pazienti con infezione da virus A (H1N1).
La totalità dei soggetti riferiva in anamnesi sintomi influenzali
classici, spesso associati a diarrea e vomito. Il tasso di ospedalizzazione è stato più elevato nei pazienti con età superiore a 40
anni rispetto a quelli di 15-39 anni (p = 0,008) o ai pazienti con
età inferiore a 14 anni (p = 0,006). I segni clinici, sintomi e complicanze respiratorie sono risultati diversi tra i due periodi di studio: sul totale, 18 pazienti (17%) erano affetti da polmonite. La
diagnosi di polmonite è stata più frequente nel secondo periodo
(37% versus 10%, p = 0,002). I pazienti con più di 50 anni hanno
mostrato una minore probabilità di diagnosi di polmonite, rispetto ai bambini di età compresa tra 0-13 anni (p = 0,049); una più
lunga durata dei sintomi prima dell’accesso in PS è stata associata
ad una maggiore probabilità di polmonite (p = 0,026). Nell’analisi filogenetica del virus dell’influenza A (H1N1) si è riscontrata
bassa variabilità sia nei geni emoagglutinina che neuroaminidasi.
Inoltre, non è stata evidenziata nessuna mutazione associata alla
resistenza neuraminidasi del virus.
Conclusioni
Questo studio, con tutti i limiti di una casistica poco omogenea e retrospettiva, ha permesso di definire fattori associati alla severità clinica del virus dell’influenza A (H1N1). Molto probabilmente i quadri clinici respiratori più gravi sono correlati all’età giovane–adulta
in quanto la popolazione più anziana ha avuto una precedente esposizione al virus con conseguente autoimmunizzazione. Nonostante
in diverse aeree geografiche (in particolare USA ed Europa del Nord)
vi fosse la circolazione di quasispecie virali che hanno presentano
mutazioni di resistenza alla terapia, in Italia non si sono osservati
cambiamenti filogenetici rispetto al ceppo virale di riferimento.
1
27
proceedings
Il silenziamento genico come strumento per lo studio della
trasduzione del segnale in fisiopatologia cardiaca e cutanea
V. Purpura, S. Raffa, F. Belleudi, V. Pittoni, S. Di Somma, M.R. Torrisi
II Facoltà di Medicina e Chirurgia, UOC Diagnostica Cellulare e UOC Medicina d’Urgenza, Azienda Ospedaliera Sant’Andrea
28
Il silenziamento genico mediante l'uso di small interfering RNA
(siRNA), in grado di interagire con uno specifico mRNA inibendone la traduzione in proteina, è una metodica ampiamente applicata
per lo studio e l'analisi dei meccanismi molecolari che regolano diversi processi cellulari. La microiniezione di siRNA, in particolare,
permette di interferire efficacemente con la funzione di molecole
proteiche inducendone la deplezione in tempi molto rapidi.
Nell'ambito degli studi sulla fisiopatologia dello scompenso cardiaco numerose evidenze sperimentali suggeriscono che l'infiammazione possa giocare un ruolo patogenetico nella regolazione
dei meccanismi molecolari coinvolti nelle risposte di adattamento cellulare alle alterazioni emodinamiche tipiche dello scompenso cardiaco. Uno dei meccanismi coinvolti riguarda la sintesi e il
rilascio del peptide natriuretico (BNP) in risposta all'attivazione
di specifiche vie di segnalazione innescate dal rilascio di citochine
infiammatorie. Nostri studi su un modello sperimentale di cardiomiociti murini hanno dimostrato che il trattamento con IL18
è in grado di produrre un incremento dell'espressione e del rilascio di BNP (Pittoni et al. submitted). La microiniezione di siRNA
per il recettore di IL18 (IL18R) e per il fattore di trascrizione
GATA4, attivato durante la trasduzione del segnale IL18-mediato,
ha mostrato che la deplezione di entrambe queste proteine inibisce gli effetti indotti dal trattamento con IL18 su espressione,
rilocalizzazione intracellulare e rilascio di BNP, dimostrando inequivocabilmente il ruolo di IL18R e del suo signaling PI3K, Akt e
GATA4-dipendente in questi processi.
Nell’ambito dello studio del ruolo del recettore tirosino chinasi
per il keratinocyte growth factor (KGFR) nel controllo del processo di differenziamento epiteliale, abbiamo utilizzato la microiniezione di siRNA per KGFR per indurre la deplezione di questo
recettore in una linea di cheratinociti umani immortalizzata non
tumorigenica. L’effetto sul differenziamento precoce è stato valutato mediante immunofluorescenza analizzando l’espressione del
marker specifico keratina1 (K1). I risultati hanno evidenziato che
la deplezione di KGFR riduce la percentuale di cellule positive
alla K1 dimostrando il ruolo chiave del recettore nel differenziamento precoce dei cheratinociti (Purpura et al. in preparation).
Questi nostri risultati indicano quindi come il silenziamento di
specifici geni mediante microiniezione sia una metodica estremamente efficace nell’analisi del ruolo di proteine coinvolte nelle
vie di segnalazione intracellulare alla base di differenti processi
fisiopatologici.
Comparison of cardiovascular and cerebrovascular events
pre and post earthquake of 6th april 2009 the abruzzo
experience
S. Sofia1, A. Melone2, E. Varrato³, R. Di Filippo4, C. Balsano*
¹U.O. di Medicina Interna, P.O. “Santissima Maria dello Splendore” di Giulianova;
3
U.O. di Medicina Interna, P.O. “ G. Mazzini” di Teramo;
4
U. O. di Medicina Interna, P.O. “S. Salvatore” dell’Aquila;
*Dipartimento di Medicina Interna e Sanità Pubblica, Università degli studi dell’Aquila.a
Each year over 500,000 earthquakes are recorded; over the past
30 years an annual average of 21 earthquakes has been reported.
Although the vast majority of the shock intensity is too low to be
warned, about 3000 shocks are felt by people and those from 7 to
11 result in significant loss of life.
Several epidemiological studies have been conducted on populations affected by natural disasters, so to constitute what is now
called “disasters epidemiology”. These studies have demonstrated the serious consequences of the earthquake on the public
health from a physical and psychological point of view in the
population affected by natural disasters.
However, although in our country natural disasters are frequent,
few epidemiological studies have been done on the effects of disasters on public health in the Abruzzo Region.
After the earthquake of 6th April 2009 Abruzzo’s area has been
paid a great attention on the psychological diseases like depression, sleep and mood disorders, psychosomatic disorders too
through the RAINBOW-SEPT studies, but less attention has been
paid on regard of acute vascular events.
That’s why our group has decided to analyze patient’s accesses to
the ER at the following hospitals: Avezzano - Sulmona, L’ Aquila,
Teramo, Giulianova, Atri and Sant’Omero.
The study will be carried out from the period between 06/04/2008
and the 31/07/2008 (preearthquake) to the period between
06/04/2009 and 31/07/2009 (post-earthquake). The aim will be
the evaluation of the incidence, in the periods chosen, of ER accesses for acute vascular events, cardiovascular and cerebrovascular events etc.).
The observational clinical study will be conducted on the Abruzzo’s population hit by the earthquake of 6th April 2009. Our study wants to determine the quantitative and qualitative differences
among the etiology of diseases characterizing patients accessing
the E.R. the pre and post-earthquake chosen periods. The data
obtained will allow us to provide a practical guidance to health
personnel and the Civil Protection – that will indicate the most
useful and effective operations during natural disasters.
References
1. Ramirez, Peek-Asa: Epidemiology of traumatic injuries from
earthquakes. Epidemiol Rev 2005;27:47-55.
2. BEN- Notiziario ISS – Vol 16 num 9: Effetti sulla salute del
Terremoto di San Giuliano 2002;
3. Norwood et al. Disaster psychiatry: principles and practice. www.pscyh.org/pract_of_psych/principles_and_practice3201.cfm
4. Ramirez, Peek-Asa: Epidemiology of traumatic injuries from
earthquakes. Epidemiol Rev 2005;27:47-55.
5. McArthur, Peek-Asa, Kraus: Injury hospitalizations before
and after the 1994 Northridge, California Earthquake.
Identificazione precoce della nefropatia associata alla
somministrazione di mezzo di contrasto: il ruolo di nuovi
marcatori
proceedings
Ulla Marco1, Saglio Elisa1, Bono Alessia1, Maggiorotto Matteo, Lomater Elisa1, Mengozzi Giulio2, Battista Stefania1
S.C. Medicina d’Urgenza A.O.U. San Giovanni Battista Torino; 2 S.C. Biochimica Clinica A.O.U. San Giovanni Battista Torino
Obiettivo dello studio
L’obiettivo del presente lavoro è valutare l’utilizzo di un biomarcatore precoce di danno renale, NGAL (Neutrophil Gelatinase
Associated Lipocalin), nella gestione del rischio di nefropatia in
pazienti sottoposti a esami radiologici con mezzo di contrasto.
Pazienti e Metodi
Tra l’ottobre 2009 e l’aprile 2010 sono stati reclutati 40 pazienti
(12 femmine e 28 maschi; età media 69,3 anni) per i quali, insieme
al nuovo biomarcatore, sono stati valutati altri parametri biochimici, la diuresi e la pressione arteriosa, al momento basale (subito
prima dell’effettuazione della procedura diagnostica) e dopo 24, 48
e 72 ore dall’esame contrastografico. Sono state effettuate 30 procedure di coronarografia, 8 TC dell’addome e del torace, 3 angio-TC.
Solo 2 pazienti non presentavano alcun fattore di rischio, mentre
18 pazienti presentavano 3 o più fattori di rischio (fino ad un massimo di 6). Una profilassi è stata condotta prima della procedura
contrastografica nella metà dei pazienti. Il dosaggio delle concentrazioni di NGAL è stato eseguito mediante un immunodosaggio a
fluorescenza (Triage® NGAL, Biosite Inc.) prodotto per l’impiego
come point-of-care con il dispositivo Triage Meter.
Risultati e Discussione
Nessun paziente ha sviluppato una nefropatia riconducibile alla
somministrazione di mezzo di contrasto nell’arco di tempo considerato, come evidenziato dalla assenza di significative variazioni temporali dei parametri misurati. Nonostante non risulti
statisticamente significativa, la variazione nel tempo delle concentrazioni di NGAL mostra una tendenza all’incremento a 24
e 48 ore. Tale andamento appare ancora più evidente quando
si consideri solamente il sottogruppo di pazienti con valori basali di NGAL < 100 ng/mL. L’aumento delle concentrazioni di
NGAL a 24 e 48 ore di distanza dalla procedura diviene statisticamente significativo nella metà della popolazione che non viene sottoposta a trattamento profilattico. Anche se la correlazione
tra NGAL e creatinina e tra NGAL e GFR in condizioni basali
nella popolazione studiata dimostra come NGAL possa riflettere indirettamente il grado di funzionalità renale, è presumibile
che l’incremento di NGAL rilevato dopo 24 e 48 ore in questo
lavoro possa riflettere un danno renale “minimo”, espressione
dell’evento lesivo iniziale in grado di innescare un danno renale acuto e possa essere predittivo dell’evoluzione del danno
stesso, rappresentato come continuum patogenetico. Se, da un
lato, l’incremento della creatinina e la riduzione del GFR sono
espressione di un’insufficienza renale funzionale, che compare
più tardivamente, dall’altro le concentrazioni di NGAL sembrano
aumentare come conseguenza di un danno renale intrinseco, che
insorge molto precocemente.
BIC2- Biomarkers in Cardiology. Diseased state biomedical
database
Anne Brüning, Andrea Pinkowski, Toni Lauterbach, Janina Stiefel, Benjamin Karow, Julia Searle, Anna Slagman, Jörn
Vollert and Martin Möckel
Charité - Universitätsmedizin Berlin, Depts. of Cardiology and Emergency Medicine
Background and conception
Each year, many patients are admitted to emergency departments
with the cardinal symptoms chest pain and dyspnea. These
symptoms can be caused by a multitude of differential diagnoses,
both cardiac and extra-cardiac. In recent years biomarkers have
greatly improved the diagnosis and risk stratification of cardiovascular diseases, but there are still unmet needs especially for a
symptom-oriented early evaluation of emergency patients. Many
promising biomarkers and biomarkers assays are being discovered but need to be assessed clinically.
A biomaterial database enables us to evaluate promising new biomarkers in clinically defined and consented blood samples, without the need to perform a laborious prospective study for each
single marker. This allows for a prompt and cost-effective testing
of multiple, diverse and relevant clinical parameters.
We set up a biomaterial database collecting samples and disease
related data from Emergency Room patients who were admitted
with either dyspnea or chest pain.
Methods
Consecutive patients with chest pain or dyspnea as their leading
symptom who presented to the Emergency Departments of the
Charité Berlin Campus Virchow Klinikum or Campus Mitte were
enrolled from spring 2008 until August 2010.
Following good clinical practice guidelines, all patients gave their
written informed consent. The trial was approved by the ethics
committee of the Charité (EA2/030/07).
Patients with a life expectancy below 6 months, an anaemia (Hb <
10g/dl), in a state of shock and patients serving a prison sentence
were excluded from the study. Inclusion criteria were an age of
above 18 years and a leading symptom of chest pain or dyspnea.
Patients with dyspnea had one study blood draw within 24 hours
after admission to the hospital. Patients with chest pain had a first
blood draw within 2 hours after admission and a second blood
draw 6 hours later. Total volume was 40ml per draw. The blood
samples were stored on ice immediately, processed within two
hours and then stored at -80°C latest after two weeks. All samples
were collected, processed and stored obeying detailed standard
operating procedures (SOPs). All collection and processing times
were recorded. Samples which did not meet the standards set in
the SOPs were discarded.
A telephone follow-up was made three months after recruitment
with assessing death or rehospitalisation for cardiac reasons.
All patient data was entered into a detailed electronic case report
form (eCRF).
Patient characteristics
We enrolled 545 consecutive patients, of which the first 509 have
1
29
proceedings
complete datasets, including the follow-up.: Of these, 300 patients had a leading symptom of dyspnea and 209 of chest pain.
In the chest pain group, we enrolled 133 male and 76 female
patients. The dyspnea group includes 182 male and 114 female
patients. To get to a full set of 200 chest pain patients with serial
samples we included more than the planned 200 patients in that
group, as a number of patients were discharged before the second
set of blood samples could be drawn.
Summary
We set up a biomaterial database with high quality blood samples
and extensive clinical data from 546 ER patients with the cardinal
symptoms dyspnea and chest pain to evaluate promising cardiovascular biomarkers for early diagnosis and personalized risk stratification of future ER patients. First biomarkers studies with new molecular cardiovascular biomarkers are on their way at the moment.
BIC6- Biomarkers in Cardiology. Cardinal symptoms and
characteristics of patient population presenting to the
Emergency Department
Martin Möckel, Rebecca Nordt, Julia Searle, Anna Slagman, Harald Storchmann, Phillip Oestereich, Angela AleAbaei, Jörn Vollert, Reinhold Müller1, Matthias Koch, and Rajan Somasundaram
Charité – Universitätsmedizin Berlin, Depts. of Emergency Medicine, Germany; 1James Cook University, Townsville, Australia
Background
The fast and safe treatment of patients presenting to the Emergency Department (ED) is of rising interest as process management
in the ED is continually sought to be improved. Thus knowing
the patient population presenting to your ED is essential.
Until now there is no methodically collected epidemiological data
about patient populations in EDs or the connection of cardinal
symptoms with diagnoses available in Germany.
Guidelines are disease-based rather than based on cardinal
complaints. Patients however typically present to the ED with
symptoms rather than a final diagnosis.
Symptom-oriented guidelines for first-hand use by ED doctors
are necessary because an increasing number of physicians in the
Emergency Room are recruited from Internal Medicine rotation
programs, resulting in a constant replacement of medical staff.
For the patients as well as for the health-system it is necessary to
find the right medical diagnosis and to initiate an effective therapy as fast as possible.
A prospective multicenter epidemiological study in the Emergency Departments on two of the main campuses of the Charité Berlin was initiated to characterize the patient population presenting
to the ED, in particular those presenting with certain cardinal
symptoms, in order to collect high-quality, symptom-oriented,
epidemiological data and to establish a new model of data assessment from the hospital information system (HIS) as a tool for
quality management.
Methods
All adult patients who were admitted to the Emergency Department of Internal Medicine from February 2nd 2009 until February
1st 2010 were included. Data assessment was performed in two
steps: In step one all direct data recorded in the ED report was
exported from the SAP-based hospital information system (HIS)
on a daily basis. Direct data describe variables which can directly be statistically analyzed such as age, gender, type of health
insurance, nationality, admission date and time, waiting times,
vital signs, tests performed, laboratory test results, risk factors,
and ICD-10 diagnoses. All patients were assigned to one of five
groups by the attending physician according to their cardinal
symptoms upon presentation to the ED: 1) chest pain, 2) abdominal pain, 3) shortness of breath, 4) headache, 5) none of the
four cardinal symptoms.
In step two data of all patients with one of the four cardinal
symptoms were manually extracted from free text fields of the hospital ED documentation sheet. The data was reviewed and then
transferred to a CRF specially designed for this study, providing
information about symptoms, patient history, medication, physical examination in the ED, diagnostic tests and therapy.
Results
We extracted and analyzed data from 34.333 patients in total,
48,8% of them male, 51,2% female. 13.776 patients were hospitalized versus 20.557 who were discharged from ED. We will
analyze the specific characteristics of these patients mainly with
respect to their cardinal symptom and their in-hospital outcome.
Conclusions
IT-regenerated epidemiological data are an essential tool for an up-to
date assessment of patient populations and the generation of symptomoriented standardized guidelines and workflows which will improve
the quality of Emergency Room processes. Furthermore these data are
essential for an effective quality management in Emergency Medicine.
Detailed results are submitted for presentation at ACC i2 summit 2011.
30
The effect of integrating the biomarker Copeptin into the
process of managing patients with suspected ACS (BIC-8)
proceedings
Anna Slagman, Sönke Petrausch, Julia Searle and Martin Möckel
Backround
The majority of patients with suspected non-ST-elevation-acute-coronary syndrome (NSTEACS) have a negative Troponin at
baseline. One of the biggest challenges for ED-physicians is the
differentiation between high-risk patients who have to stay in hospital for further monitoring and low-risk patients who can safely
be discharged to ambulant care.
Our study objective is to quantify the benefit of integrating the
new biomarker Copeptin into the process of managing patients
with suspected NSTEACS with a negative baseline Troponin test
result in the Emergency Department. Our Hypothesis is that
patients who test negative for Copeptin, a biomarker of severe,
life-threatening stress, at admission are at low risk of ACS. This
hypothesis is supported by results from clinical trials which showed a high negative predictive value for Copeptin in addition to
Troponin in patients with acute myocardial infarction.
Methods
We will conduct an interventional multicenter biomarker randomized controlled clinical trial to assess the benefit of a rule-out
multimarker strategy including Troponin and Copeptin to identify low-risk chest pain patients who can safely be discharged to
ambulant care.
Our aim is to enroll a minimum of 892 patients within one year
in 4 study-centers in Germany.
Inclusion criteria are typical chest pain suggestive of unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI)
and a negative baseline Troponin (Cut off for standard Troponin
T = 0.03μg/L; high sensitive Troponin T = 0.014 μg/L).
Excluded from participation are patients with ST-elevation myocardial infarction (STEMI), continuing chest pain or recurrent
episodes of chest pain under appropriate therapy, high-risk ACS
patients who need to be hospitalized for reasons irrespective of
their initial Troponin result, patients who need to be hospitalized
for other medical reasons, patients in need of urgent life-saving
interventions and patients with a life expectancy < 6 months.
Also excluded are patients with any condition that leads the treating physician to not consider the patient eligible for the trial.
The patients will be randomized into a standard process or experimental process.
In the experimental arm of the study Copeptin will influence further patient management. Eligible patients with a negative Copeptin (cut-off: 10pmol/L) will be considered as low-risk patients
and will be discharged into ambulant care. Eligible patients with
a positive Copeptin will be treated according to the current standard of care (SOC). To ensure patient safety an internet-based
portal for the management of patient referrals between hospitals
and resident cardiologists will be established.
Patients in the standard arm will be admitted to the CPU and will
be treated according to the current guidelines for patients with
suspected ACS. The Copeptin results of these patients will not
be revealed to the treating physicians. Primary endpoint is the
rate of major adverse cardiovascular events at 30 and 90 days.
Secondary endpoints evaluate efficacy, including rate of patients
with coronary angiography and PCI, safety, cost effectiveness and
patient satisfaction of the new process.
Timeschedule/Aim of the trial
First results are expected in spring 2012. If the new processes are
shown to be efficient, safe, cost-effective and/or improve patient
satisfaction this trial could help implementing Copeptin as a novel
biomarker for the rapid rule out of NSTEMI in clinical practice.
Management of atrial fibrillation in emergency
department
M.G. D’Angelo2, P. Pitto2, P. Costelli2, F. Catalani1-2, M. Greco1-2, P. Giuntini, P. Campodonico1-2
Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Università degli Studi di Genova;
A.O.C. Pronto Soccorso e Medicina d’Urgenza, A.O.U. San Martino, Genovae
1
2
We propose our protocol for clinical trial about treatment and
management of recent-onset Atrial Fibrillation (AF) in Emergency Department.
Atrial Fibrillation remains the most common and most challenging arrhythmia. Although several new treatment modalities are
available to restore and maintain sinus rhythm, the long-term
success of such a strategy remains disappointing, often making
rate control a good alternative.
Rhythm control of AF is generally preferred over rate control in
the belief that it offers better symptomatic relief and quality of life
and eliminates need for anticoagulation.
Rhythm control remains first choice for patients with initial episodes
or highly symptomatic episodes of AF and for patients who have a
high chance of remaining in long- term sinus rhythm (young patients,
normotensive, normal left atrium size, previous short AF episodes).
Objective
1)Evaluation of rhythm control in patients with AF lasting < 48h.
2)Evaluation of electrical cardioversion vs Pharmacological one.
3) Comparison of: a) Successful electrical cardioversions vs medical ones; b) Efficacy, adverse effects and cardioversion time of
antiarrhythmic drugs in three classes of ages; c)Adherence to
internal guidelines in order to assess the destination of patients
(admission or discharge from Emergency Room-ER or from Observation Unit-OU).
Population
All patients evaluated in the Emergency Department with recentonset AF. They can be treated elettrically or pharmacologically
with amiodarone, flecainide or propafenone.
Methods
We analysed a random group of 523 patients with AF(48,6% with
recent-onset AF) who were visited in the Emergency Department
of San Martino University Hospital since 2006 to 2009, three months per year. Patients were divided in three age groups: 94 patients
< 65 years; 117 patients from 65 to 80; 43 patients > 80 years.
We assessed the following clinical data: Sex, Age, Heart rate, Ar-
Charité – Universitätsmedizin Berlin, Dept. of Cardiology and Emergency Medicine
31
proceedings
terial pressure, Oxygen saturation, Left ventricular ejection fraction, Coagulation statement.
2. Successful Cardioversion performed in ER or OU/total successful Cardioversion):138/247 (0,5).
Results
We performed medical cardioversion in 194 patients (76,4%),
electrical cardioversion in 49 patients (19,3%), 11 patients
(4,3%) obtained spontaneous cardioversion.
We compared, considering their efficacy and timing in restoring
sinus rhythm, Amiodarone, Flecainide and Propafenone.
Electrical cardioversion was effective in 100% of patients while
medical cardioversion obtained rhythm control in 90% of patients.
Cardioversion time was within 3 hours in 62% of patients using
Flecainide, in 40,4 % of patients using Propafenone and in 20,7%
of patients receiving Amiodarone.
Regarding the management aspects of patients with AF in the
Emergency Department we used Performance Indicators:
1. Number of successful cardioversions/ number of candidates:
247/254 (0,9);
On the basis of the available data we demonstrate that:
- Most patients candidated to cardioversion obtained restoring
of sinus rhythm;
- More than half of all patients evaluated were rapidly treated
in the ER or in OU;
- The Adherence to Guidelines was 418/523 (0,80).
Conclusion
As it is well known electrical cardioversion is more effective and
safe in young and in older patients with normal left ventricular
function without underlying heart disease.
Flecainide is effective and fast in converting recent onset AF. In older
patients Amiodarone is more useful and safe according to literature.
During the period of study (four years) despite of the great number
of physicians of our team we observed a good adherence to guidelines both in clinical and management setting.
Bioelectrical Impedance Vector Analysis (BIVA) for the
Assessment of Peripheral Congestion in Patients with
Acute Dyspnea
Marta Codognottoa, Gianna Vettoreb, Mario Plebanic, Antonio Piccolia
Departments of aMedical and Surgical Sciences, bEmergency, and cLaboratory Medicine University of Padova, Italy
Background
There is no gold standard for the differential diagnosis of acute
dyspnea. The usefulness of NT-proBNP and lung ultrasound in
identification of heart failure in dyspneic patients is supported
by many studies. No previous study evaluated the contribution
of BIVA to the discrimination between cardiac and non-cardiac
dyspnea.
Aim
To establish the relationship between lung ultrasound (detecting
lung congestion), NT-proBNP (detecting ventricular dysfunction), and BIVA (detecting peripheral congestion) in patients
with acute dyspnea.
Methods
We studied 315 patients (50-95 yrs), with eGFR ≥ 30 mL/
min/1.73m2, presenting at emergency department with dyspnea.
Dyspnea was classified into cardiac (n= 169) and non-cardiac (n=
146) based on physical examination, electrocardiogram, chest
X-ray, NT-proBNP, and lung ultrasound (B-lines of lung congestion). Impedance is a vector (Z) with two components, the resistance, R (function of intra- and extracellular fluid volume) and
the reactance, Xc (function of tissue cell membrane). Bioimpedance measurements at 50 kHz were transformed into standardized Zscores, Z(R) and Z(Xc), that is Z(R)= (R – mean R)/SD and Z(Xc)=
(Xc – mean Xc)/SD, with mean and SD from the reference healthy
population. Z-scores are expressed in SD [Piccoli et al. Nutrition
2002; 18:153-157]. The intersubject variability of Z is represented
by the bivariate normal distribution (50%, 75%, and 95% tolerance
ellipses). In BIVA method, vector positions in the lower or higher
half of reference, tolerance ellipses indicate peripheral congestion
or progressive decrease in tissue fluid volume, respectively.
Results
Impedance vector components Z(R) and Z(Xc) were both significantly decreased in cardiac dyspnea group. The mean vector of
the group with non-cardiac dyspnea was close to 0 SD of both
components indicating a normal tissue fluid volume. The mean
vector of the group with cardiac dyspnea without peripheral
edema was close to the lower pole of the 50% tolerance ellipse
indicating a mild increase in tissue fluid volume (i.e., latent peripheral congestion). The ROC curve indicated that Z(Xc) = -1 SD
(lower pole of the 50% tolerance ellipse) discriminated between
cardiac, Z(Xc) < -1, vs non-cardiac dyspnea, Z(Xc) > -1, with 69%
sensitivity and 79% specificity (AUC 80%). Peripheral congestion
(wet BIVA) without lung congestion (negative ultrasound) was
associated with an increased NT-proBNP by two-fold compared
to the condition without peripheral congestion (dry BIVA). In
patients with non-cardiac dyspnea, negative lung ultrasound, and
dry BIVA, the NT-proBNP concentration was the lowermost of the
study population. In patients with negative lung ultrasound and
wet BIVA, the increase in NT-proBNP was twofold with respect to
the former group. In patients with cardiac dyspnea and a positive
lung ultrasound, the NT-proBNP levels were the highest.
Conclusions
Peripheral congestion without lung congestion may result in myocardial stretch with increased NT-proBNP release. The optimal evaluation of a dyspneic patient should detect peripheral congestion
with BIVA and lung congestion with lung ultrasound.
32
Neutrophil gelatinase-associated lipocalin (NGAL) e cistatina
C come marker precoci di AKI (Acute Kidney Injury)
proceedings
Neutrophil gelatinase-associated lipocalin (NGAL) è un nuovo
marker precoce di AKI (Acute Kidney Injury). Molti studi clinici
ne hanno dimostrato l’utilità attraverso la misurazione dei livelli di NGAL nelle urine in pazienti con danno renale acuto. La
cistatina-C è una una proteina di basso peso molecolare, prodotta
in quantità pressoché costante da tutte le cellule nucleate liberamente filtrata, riassorbita e catabolizzata per il 99% circa nel tubulo
rappresentando quindi un ottimo marker endogeno di funzionalità
renale. Il nostro studio si prefigge di verificare l’utilità di ripetute
misurazioni di NGAL plasmatico e cistatina C in tutti i pazienti
giunti in Pronto Soccorso e successivamente ammessi nel Reparto
di Medicina d’Urgenza al fine di: stratificare il rischio di danno
renale precoce (AKI), valutarne la severità, impostare rapidamente
una terapia adeguata, stabilire la prognosi. Nella fase preliminare
nel nostro centro sono stati arruolati 200 pazienti (123 M – 77 F),
con un’età media di 73,5 ± 13,7 anni, le patologie più frequenti in
anamnesi sono risultate ipertensione arteriosa, BPCO, diabete mellito, cardiopatia ischemica cronica. 47 pazienti erano affetti da AKI
(valutato attraverso i criteri RIFLE). Sono stati effettuati 6 prelievi
ematici rispettivamente a tempo 0, 6 ore, 12 ore, 24 ore, 48 ore e 72
ore misurando nel plasma NGAL, creatinina e cistatina C. In conclusione, dai risultati preliminari del nostro studio si evince quanto segue: l’ incidenza di AKI nei pazienti che giungono in Pronto
Soccorso e, successivamente, necessitano di ricovero, è elevata
(20%); tra le cause principali da considerare come determinanti
per lo sviluppo di AKI in tali pazienti, lo scompenso cardiaco acuto
e le BPCO riacutizzate rappresentano le patologie predominanti
(soggetti maggiormente a rischio); la preesistenza di Ipertensione
Arteriosa sembra determinante nell’ incidenza di tale patologia. La
valutazione del nuovo biomarker, NGAL, sembra realmente promettente per valutare tali pazienti al momento dell’ ammissione in
Pronto Soccorso, infatti da questi dati preliminari appare evidente
che valori di NGAL inferiori a 110 ng/dl correlano con una scarsa
probabilità di sviluppare AKI (VPN 89%). L’elaborazione dei campioni di plasma per il dosaggio della cistatina C è ancora in corso
ma a breve valuteremo la reale correlazione tra cistatina C ed AKI e
l’efficacia della misurazione combinata di NGAL e cistatina C nella
diagnosi precoce di danno acuto renale.
Audit Clinico sulla Durata della TAO nei pazienti con E.P.
idiopatica
Casarsa C, Orso D, Perich D, Mariza S, Mearelli F.
Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Università degli Studi di Trieste
Background
La durata della terapia anticoagulante orale nel paziente con embolia polmonare discende dal rischio della ricorrenza dell’evento,
dal rischio di sanguinamento e dalla stessa preferenza del paziente1.
I pazienti con embolia polmonare unprovoked (idiopatica) e
quelli con embolia polmonare ricorrente sono candidati alla terapia anticoagulante a lungo termine con una periodica rivalutazione del rapporto rischio/beneficio2. In tali condizioni i fattori di
rischio per sanguinamento maggiore sono molti, e tra questi: l’età
avanzata (>75 anni), il pregresso sanguinamento gastrointestinale; inoltre, dalla compresenza di: pregresso ictus non cardiogeno,
insufficienza renale cronica, malattia epatica, terapia antiaggregante ed altre malattie acute o croniche severe. Una particolare
menzione merita lo scarso controllo della terapia anticoagulante3-11.
Disegno dello studio
Studio retrospettivo tra i pazienti affetti da embolia polmonare
unprovoked trattati con anticoagulante che abbiano presentato,
durante il loro trattamento, un evento emorragico maggiore, definito come un episodio che abbia richiesto il ricovero e/o il trattamento con vitamina K.
End point
Valutare la prevalenza dei fattori di rischio per sanguinamento
per definire uno “scoring” che assista la valutazione del rapporto
rischio/beneficio nella durata della terapia anticoagulante.
I risultati ottenuti, in questa fase preliminare, saranno oggetto di
una successiva validazione prospettica.
References
Torbicki A, Perrier A, Konstantinides S. Guidelines on the diagnosis and management of acute pulmonary embolism. Eur
Heart J 2008; 29, 2276–315.
Agnelli G and Becattini C. Acute Pulmonary Embolism. N Engl J
Med 2010; 363:266-74.
Kearon C, Ginsberg JS, Kovacs MJ, et al. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin
therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med 2003; 349:631–9.
Schulman S, Beyth RJ, Kearon C, et al. Hemorrhagic complications of anticoagulant and thrombolytic treatment. American
College of Chest Physicians evidence-based clinical practice
guidelines (8th edition). Chest 2008; 133 (6 suppl): 257S–
98S.
Beyth RJ, Quinn L, Landefeld CS. A multicomponent intervention to prevent major bleeding complications in older patients receiving warfarin: a randomized, controlled trial. Ann
Intern Med 2000; 133:687–95.
Beyth RJ, Quinn LM, Landefeld S. Prospective evaluation of an
index for predicting the risk of major bleeding in outpatients
treated with warfarin. Am J Med 1998; 105:91–9.
Dentali F, Douketis JD, Lim W, et al. Combined aspirin oral anticoagulant therapy compared with oral anticoagulant therapy
alone among patients at risk for cardiovascular disease: a
meta-analysis of randomized trials. Arch Intern Med 2007;
167:117–24.
Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes
for predicting hemorrhage: results from the National Registry
Cristina Bongiovanni
33
proceedings
of Atrial Fibrillation (NRAF). Am Heart J 2006; 151:713–19
Kuijer PMM, Hutten BA, Prins MH, et al. Prediction of the risk of
bleeding during anticoagulant treatment for venousthromboembolism. Arch Intern Med 1999; 159:457–60
Palareti G, Leali N, Coccheri S, et al. Bleeding complications of
oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Lancet 1996; 348:423–8
Pengo V, Legnani C, Noventa F, et al. Oral anticoagulant therapy
in patients with nonrheumatic atrial fibrillation and risk of
bleeding: a Multicenter Inception Cohort Study. Thromb Haemost 2001; 85:418–22.
Epidemiology and Treatment of Atrial Fibrillation in
Emergency Department: Preliminary Results of the
Cardioversion of Atrial Fibrillation in Emergency (CAFÉ)
Study
Francesco Buccellettia, Salvatore Di Sommab, Alberto Galantec, Francesco Pugliesed, Filippo Alegianie, Giuliano
Bertazzonif, Nicolò Gentiloni Silveria, Francesco Franceschi
34
a
Department of Emergency Medicine, Catholic University of the Sacred Heart, Rome - Italy; b Department of Emergency Medicine, Sant’Andrea
Hospital, La Sapienza University, Rome - Italy; c Department of Emergency Medicine, University of Tor Vergata, Rome - Italy; d Department of
Emergency Medicine, Sandro Pertini Hopsital, Rome - Italy; e Department of Emergency Medicine, Fatebenefratelli-Isola Tiberina Hospital, Rome
- Italy; f Department of Emergency Medicine, Umberto I Hospital, La Sapienza University, Rome - Italy
Background
Atrial Fibrillation (AF) management is still matter of debate. Research is largely based in cardiology setting and few data exist on
management of AF in Emergency Department (ED). This study
investigated which factors drive different AF treatments in ED,
describing their use in different hospitals. Finally, efficacy of different strategies in terms of cardioversion in ED is analysed.
Methods
Charts of patients treated in 6 EDs in Italy for “atrial fibrillation”,
in a 24 consecutive months period, were reviewed and analysed.
Demographics, comorbidities, treatment strategy and ED outcome were collected. Inclusion criteria were symptoms onset <3
weeks and hemodynamic stable conditions at presentation.
Propensity score was used to adjust for baseline clinical characteristics and to compare different treatments efficacy.
Results
3085 patients were included in the analysis. Variables associated
with a rhythm control strategy were symptoms onset <48 hours,
age, dyspnea, plpitations, renal failure and mechanical valve.
Different EDs applied different strategies in terms of drugs used
and electric cardioversion, showing heterogeneity in AF management. Adjusting for propensity score, electric cardioversion and
antiarrhythmic drugs of class Ic were more effective than waitand-watch in ED.
Conclusion
Despite international guidelines are respected, AF management is
heterogeneous in different ED settings. Rhythm control strategy
with electric cardioversion and Class Ic drugs is more effective
than wait-and watch approach during ED visit.
Further research, toward an evidence-based, approach to AF in
ED, is warranted.
Role of Gas6 protein in thromboembolic diseases: effects
on human platelets activation
Luigi Castello, Alessandra Bertoni, Clara Di Vito, Federica Alciato, Elena Ranza, Claudio Michelone, Pier Paolo
Sainaghi, Gian Carlo Avanzi
Dipartimento di Medicina Clinica e Sperimentale. Università del Piemonte Orientale “A. Avogadro”
The identification of new molecules involved in the regulation of
platelet activation represent an important goal in order to decrease mortality and morbidity due to acute thromboembolic events
as myocardial infarction, stroke and pulmonary embolism.
Gas6 is a vitamin K-dependent protein produced by many cells
types and it binds to one of three receptors of the TAM family
(Tyro3, Axl or Mer). Gas6 has been showed to be involved in
widespread physiologic roles, such as cell adhesion, migration,
growth and survival. Moreover, Gas6 and its receptors seem
to have a role in the pathogenesis of thrombosis. The current
hypothesis indicate Gas6 as an amplifier of the platelet response
to other agonists being unable to evoke any activation per se.
Therefore the inhibition of Gas6 might constitute a promising
therapeutic strategy to prevent thromboembolic events avoiding
bleeding side effects. Dicumarolics act as vitamin K inhibitors leading to a reduction in gamma-carboxilation of many proteins
including several blood coagulation factors and Gas6.
The objective of our project is to clarify if dicumarolics affect
platelet aggregation and whether the effect may be due to the
Gas6 inhibition. For this purpose we recruited 19 patients treated
with dicumarolics (with stable INR values) and 19 controls at the
Emergency Unit of “Maggiore della Carità” Hospital in Novara.
We evaluated different aggregation tests in different experimental conditions on both washed platelets and platelet rich plasma
(PRP). For each agonist (i.e. U46619, ADP) we analyzed the aggregation curve lag time, slope and amplitude.
We found a statistically significant reduction in the PRP slope of
the patients treated with dicumarolics with respect to controls.
In particular 5 μM ADP generated a slope of 96.32° (±16.18°) in
patients and of 122.45° (±22.33°) in controls: this difference is statistically significant (p <0.01). In the presence of 3 μM ADP there
was a statistically significant difference (p <0.05) since there was a
slope of 96.5° (±12.88°) in patients and of 112,5° (±19.04°) in controls. Finally, also in the presence of ADP 1 μM the slope showed
significant changes between the two populations (p <0.01) with
values of 56.28° (±15.41°) in patients and 89.07° (±18.45°) in controls. In the presence of 2 μM U46619 it was observed a slope of
105° (±22.66°) in patients and 127.38° (±22.82°) in controls with
a p<0.05. We also compared all the slopes obtained by stimulation
with 1 μM U46619. In the patients we observed that the slope on
washed platelets was of 71.00° (±22.75°), while on the PRP it was of
94.50° (±4.78°); in the controls the slope obtained on washed platelets was of 56.66° (±10.96°), while on the PRP it was of 146.33°
(±5.77°). The slope value of the control PRP is significantly higher
than that obtained in other experimental conditions, that are PRP of
patients treated with dicumarolics and washed platelets (p<0.01).
This evaluation leads us to observe that in the control PRP, which is
the only one in which Gas6 is present in the gamma-carboxylated
form, the slope assumed higher values; however, where the protein
is not present (washed platelets) or it is inhibited by dicumarolics
(PRP of patients) the slope was lower. In conclusion, in our model,
dicumarolics seem to modulate platelet aggregation by lowering the
rate of platelet aggregation through inhibition of plasma Gas6 and
not through a direct action on platelets.
proceedings
Immigrati e PS: una nuova sfida. Dati 2008-2009 Pronto
Soccorso Ospedale Sandro Pertini
F. Paglia°, M. Salim°, A. Celestini*, A. Revello°, F. R. Pugliese°
Background
La sempre maggiore presenza di persone di nazionalità non italiana, presenti sul nostro territorio nazionale, rappresenta per la Medicina d’Urgenza una nuova sfida per affrontare patologie vecchie
e nuove in contesti socio-culturali spesso non conosciuti. Per avere l’opportunità di conoscere più a fondo questa nuova realtà, abbiamo effettuato un’analisi retrospettiva dei pazienti di nazionalità
non italiana che sono stati curati presso il PS del nostro ospedale.
Materiali e Metodi
Abbiamo analizzato retrospettivamente l’accesso al Pronto Soccorso dell’Ospedale Sandro Pertini dei pazienti stranieri negli
anni 2008 e 2009. Oltre ai parametri demografici (età, sesso, nazionalità), sono stati presi in considerazione i seguenti parametri: livello di triage, disciplina di competenza, modalità d’arrivo
e esito. In ultimo è stata analizzata la diagnosi di ricovero o di
dimissione.
Risultati
Nel periodo 2008-2009 sono stati visitati presso il PS dell’Ospedale Sandro Pertini 21.342 pazienti di nazionalità non italiana,
che corrispondono quindi a circa il 13% del totale degli accessi
in Pronto Soccorso (2008-12,8%; 2009-13,1%). L’età adulta (>14
anni) rappresentava il 94,5%, il 57,1% era di sesso femminile;
nell’età pediatrica invece il sesso più rappresentato è quello maschile (51%). La nazione più rappresentata è stata la Romania
(28.9%), seguita da Egitto (4.4%), Bangladesh (4.1%), SerbiaMontenegro (3.9%), Perù (3.6%), Polonia (3.4%), Albania (3.1%)
e Filippine (2.9%). I pazienti di nazionalità cinese sono risultati
l’1.7% del totale dei pazienti stranieri. Il 47.4% degli accessi era
di competenza medica, mentre il 33.4% di pertinenza ortopedica
o chirurgica. Per il sesso femminile il 34.5% degli accessi era di
competenza ginecologica, in linea con i dati nazionali. La valutazione di triage ha assegnato il codice verde al 74% dei pazienti,
mentre il 9.7% è stato valutato come giallo o rosso. Il 76% dei pazienti ha raggiunto il PS con mezzi autonomi ed il 15,3% è stato
ricoverato o trasferito presso un altro nosocomio.
Le patologie d’accesso rispecchiano i dati del Ministero: la diagnosi più frequente è relativa al decorso di una gravidanza (8.8%
del totale e 15.4% dei pazienti di sesso femminile), seguita da dolore addominale (5.6%), sifilide (3.9%), dolore toracico (3.5%),
colica renale (2.2%) e cefalea (1.7%). Interessante è l’andamento
di presentazione settimanale: per gli adulti la massima frequenza
di accessi è il martedì e giovedì; mentre per l’età pediatrica il martedì e la domenica
Conclusioni
I pazienti di nazionalità straniera rappresentano sempre più una
parte consistente della totalità degli accessi di Pronto Soccorso.
La popolazione straniera che si rivolge al nostro PS appartiene
ai cluster etnici relativi a 8 paesi a basso reddito, di cui la maggioranza proviene dalla Romania. Le varie nazionalità non sono
rappresentate in maniera proporzionale rispetto alla loro presenza sul territorio italiano: ad esempio, i pazienti provenienti dalla
Cina, sono solo l’1.7% del totale, benché la comunità cinese sia
una delle più numerose in Italia. Gli stranieri non sembrano ancora sufficientemente informati sulla possibilità di usufruire del
118 (più dei tre quarti degli accessi avviene con mezzi propri).
La diagnosi di dimissione ci dimostra come il PS venga spesso
utilizzato per controlli durante la gravidanza, che in molti casi
potrebbero avvenire in un ambulatorio dedicato. Infine, il fatto
che il 3.9% dei pazienti sia giunto in PS per la sifilide, induce a
pensare come il mosaico della patologie nei nostri PS, potrebbe
nel giro di qualche anno cambiare radicalmente.
HRTC role in the diagnosis of H1N1 Pneumonia
M. Vinciguerra, A. Pallavicino, E. Teti, M.V. Tomassi, L. G. Vismara, C. De Dominicis
°DEA Ospedale S. Pertini Roma; *Cardiologia Ospedale Sant’Andrea Roma/Ospedale San Paolo Civitavecchia
Radiodiagnostic Department – S. Andrea Hospital (Rome); Infectious Diseases Department – S. Andrea Hospital (Rome)
Background And Objectives
A/H1N1 flu originally appeared in Mexico in March 2009 and later it
quickly extended all over the world. The first cases in Europe dated
at May 2009 and, at June, WHO declared the pandemic emergency.
The study includes patients examined from October to Decem-
ber 2009 and it wants to point out an essential multidisciplinary
management (clinical and imaging) of the A/H1N1 infection. In
particular it underlines the imaging role as initial approach to
the patient (chest x-ray) and as fundamental way to identify any
complications (HRTC) stimating following therapeutic chooses.
35
proceedings
36
Patients And Methods
18 patients have been screened, 10 males and 8 females in a range
between 21 and 65 years old, hospitalized at S. Andrea Hospital
since October to December 2009. All of them presented signs and
symptoms of A/H1N1v flu described in the CDC guide lines (fever, headache, weakness, dry cough, sore throat, rhinitis, myalgia, stomach pit’s pain), RT-PCR positive for H1N1v and concomitant chronic diseases or responsible of immunitary depression.
The patients have been evaluated with chest x-ray at the beginning of the symptoms and then HRTC in case of no response to
the antiviral therapy with Oseltamivir.
Results
4 of the 18 patients examined, presented a rapid improvement
with antiviral therapy, whereas others 14 patients have been submitted to in-depth examinations HRTC (2 of them initially presented negative radiography) and to further antiviral therapeutic
cycle because of the persistent case history. The lesions presented
in the 14 cases at HRTC were: small consolidated areas especially
in peripheral sites (75%), patchy ground glass opacities (75%),
thickening of inter-intralobular septs (87,5%), pleural effusion
(50%). Pulmonary involvement has been bilateral in all patients
except for one; pulmonary zones more interested were lower presenting a diffuse distribution of the lesions (87,5%). All of the
patients showed clinical and imaging improvement at the follow-
up except for one patient dead during the admission for ARDS
complication and bilateral alveolar interest.
Conclusions
Chest radiograph confirms itself as an adeguate tool for identifying A/H1N1 related pneumonia, according to clinical-serological findings. However, in few selected cases, HRTC results more
sensible in diagnosis of pulmonary’s complications, above all in
clinical radiological mismatch and in those case histories seriously compromised by interstitial and small airways’ interest, not
evident at x-ray. Finally our study points out a new localization
of thickening of interstitial septs in the subpleural site followed
by the appearance of ground glass opacities in short time, which
has never described in Letterature earlier.
Bibliography
-High-resolution CT findings in a patient with influenza A
(H1N1) virus-associated pneumonia. Edson Marchiori, Glàucia
Zanetti, Bruno Hochhegger, Claudio Mauro Mano. The british
Journal of Radiology, January 2010.
-Swine-Origin Influenza A (H1N1) Viral Infection: Radiographic
and CT Findings. Amr M Ajlan, Brendan Quiney, Savvas Nicolaou. AJR2009; 193:1494-1499.
-Chest Radiographic and CT Findings in Novel Swine-Origin
Influenza A (H1N1) Virus (S-OIV) Infection. Prachi P. Agarwal,
Sandro Cinti, Ella A. Kazerooni. AJR 2009; 193:1-6.
Cocaine abuse in patients referred to the Emergency
Department: the Policlinico Tor Vergata experience
Guarino S., Legramante J.M., Gallù M., A. Galante
Medicina d’ Urgenza, PTV Dipartimento di Medicina Interna, Università di Tor Vergata
Introduction
The rise of cocaine use in Europe, as well as in many countries
outside Europe, has increased the number of emergencies and
hospitalizations due to emergency situations related to the abuse.
Objective
1) provide information about the extent of the phenomenon with
reference to the reality of Policlinico Tor Vergata, over the period
May 2004-April 2007, 2) to identify the distinctive characteristics
of those who come to the emergency department for conditions
related to cocaine abuse, 3) identify the causes that most often
push these patients to seek emergency department and the codes
assigned priority, 4) evaluate the impact of the phenomenon in
the emergency room trying determining which are the periods
of more crowd and therefore more workload within 24 hours, 12
months, and days of the week.
Materials and Methods
Patients included in the study were tested for urinary screening
based on clinical and / or medico-legal criteria (request of the
Judicial Authority). The screening test was also used to search
for the positivity to other drugs. Ethanol was searched by determining plasma. Urinary levels of cocaine metabolites greater than
or equal to 300 ng / ml were considered positive. Sex, age, nationality, date of access (time, day of week, month, year), access
code, diagnosis, acceptance, positive to cocaine, alone or multiple drugs of abuse, were analyzed.
Results
The study included 141 subjects, 119 (84.4%) male and 22
(15.6%) female, 136 (96.5%) of Italian nationality and 5 other
countries. 36 subjects (25%) in age between 15 and 24, 90 (64%)
between 25 and 44 years, 15 (11%) between 44 and 64 years.
The month with the highest turnout was in August (17 patients)
with a slight predominance of the accesses in the late afternoon (around 19.00). The more crowded day was Thursday with
27 hits, followed by Saturday with 25. The most accesses were
caused by a car accident (46 patients 36%), followed by cardiovascular causes (25 patients, 20%), aggression (15 patients, 12%),
abdominal pain (5 patients, 4%), seizure (4 patients, 3%), other
(32 patients, 25%). Most of the patients were assigned a green
code (60 patients, 42.5%), to 51 (36.2%) a red code, 30 yellow
codes(31.3%). Among the 141 patients enrolled in our study, 92
(65.3%) were positive only to cocaine, whereas 49 (34.7%) positive results simultaneously in more than one abuse substance (9
of these 49 patients positive at the same time at more than two
drugs). The most frequent association was with alcohol (24 patients, 48.9%), followed by opioids (12 patients, 24.5%), benzodiazepines (10 patients, 20.4%), the cannabis (3 patients, 6.2%).
Conclusion
the distinctive features of those who come to the emergency room
for illnesses related to cocaine abuse are male, Italian nationality,
on average 32 years. Such patients go to the ER mostly in the
late afternoon after a car accident, they get a green code and are
positive for at least another abuse substance.
Management of Cancer-related pain in Emergency
proceedings
Legramante J.M.
More than 930 thousands people die every year due to cancerrelated diseases in the 15 EU countries accounting for about 40%
of the overall deaths (about 2.5 milion/year). Moreover, cancer
has a great social impact representing the second death cause in
Europe after cardiovascular diseases and due to the progressive
aging population this social impact is gradually increasing. Despite
epidemiologic studies of cancer are substantially developing in
Italy after the activation of the Banca Dati Italiana dei Registri dei
Tumori, data concerning patients affected by cancer presenting in
Emergency Department (ED) are still lacking. A study performed in
Piemonte (Italy) shows that about 0.4% of the patients presenting
in ED are affected by cancer-related diseases representing twice
the rate of yellow and red code as compared to the total number
of patients presenting to the ED. Also the number of patients who
die in ED (1.2% vs 0.1%) and charged in the hospital (53.6%
vs 12.2%) are greater for cancer-related patients as compared to
the total number of patients presenting in ED. In line with these
observations a study performed in the Emergency Department of
our University Hospital (Policlinico Tor Vergata) is noteworthy.
We have evaluated the number of patients presenting in ED who
were diagnosed for a previously ignored cancer-related disease.
In two years about 332 patients received a novel diagnosis of
cancer-related disease in the Emergency Department. Therefore
these indirect data clearly show that cancer represents a real
challenge for Emergency Department. Moreover, about 80%
of cancer-related patients suffer from chronic pain and ED is
often a place of refuge. There are significant barriers to optimal
pain management in the emergency setting, including lack of
knowledge, inexperienced clinicians, myths about addiction, and
fears of complications after discharge. These factors contribute
to unnecessary suffering not only for the patient but also for
family and caregivers. Malignant pain is highly responsive to
medication. Adequate malignant pain control is possible in more
than 90% of patients if established therapeutic approaches are
applied systematically in any practice setting, including the ED.
It has been suggested that management of an acute pain crisis in
a patient with advanced cancer ‘‘is as much a crisis as a code,’’ and
emergency clinicians should, and can, become comfortable caring
for patients with cancer in acute pain. Patients with cancer often
present to the ED because their pain is unmanageable. Although
there are multiple physiologic possibilities for inadequate pain
control, the emergency clinician should also be aware of the many
psychosocial factors contributing to oligoanalgesia in the cancer
patient. Depression, unresolved spiritual or social concerns,
and misconceptions of prescribed medications may interfere
with adequate treatment. With a properly focused evaluation,
the treatment of unresolved pain in the cancer patient can be
performed rapidly and effectively in the ED.
General principles of good pain assessment are particularly
important in the patient presenting to the ED with malignancy
and are not different from those used in a outpatient pain
unit. The problem is the setting, completely different from
an outpatient ambulatory. ED crowding, the need to see the
patient as soon as possible, the great number of patients to be
managed by one doctor, make the assessment of pain not always
feasible. Accordingly, the definition of severity, character, likely
etiology, timing and location, exacerbating and relieving factors,
and associated symptoms which usually provides essential
information for proper management, becomes a difficult task in
ED. Moreover, to collect details of the clinical history may reveal
particular cancer pain syndromes, some of which require urgent
diagnosis and intervention to prevent permanent functional
impairment. Therefore by attempting to reach a compromise
between the ED frenetic activity with the need for an adequate
pain assessment, effective therapy can be quickly implemented in
the ED. Also because a rapid response to a pain crisis is essential
for patients both with early stage disease and, particularly, those
at the end of life. Failure to adequately manage a pain crisis early
in the disease course encumbers both the patient and family with
the fear that escalating pain and lack of effective treatment will
dominate their final days of life. This issue is well explained by
the sentence tracked in a recent paper “Managing acute pain
crisis in a patient with advanced cancer. This is as much of a crisis
as a code” (JAMA 2008; 299 (12): 1457-1467).
Venous Thromboembolism Prophylaxis In Medically Ill
Patients.
Policlinico Tor Vergata Emergency Medicine Experience
Di Lecce V.N., Gallù M., Gravina A., Legramante J.M., Galante A.
Medicina d’Urgenza, Policlinico Tor Vergata, Dipartimento di Medicina Interna, Università di Tor Vergata
Available data indicate that the frequency of deep vein thrombosis in medically ill patients, in the absence of prophylaxis, varies
from 10% to 26%. Pulmonary embolism is responsible for up to
10% of deaths that occur in hospital, and 75% of fatal pulmonary
emboli are in medical patients. Evidence-based guidelines recommend that acutely ill hospitalized medical patients who are at risk
of venous thromboembolism (VTE) should receive prophylaxis.
Despite the existence of these guidelines, VTE prophylaxis remains underused (IMPROVE and ENDORSE study). The first reason appears to be a lack of awareness of both the disease and the
evidence based guidelines. Physicians’ fear of potential bleeding
complications is the second reason for not using prophylaxis. The
aim of this study was to assess the prevalence of patients at risk
of VTE in our Emergency Medicien Division, to determine the
proportion of these hospital setting at risk patients who receveid
prophylaxis as raccomended by the American College of Chest
Physician (ACCP 2008) evidence based consensus guidelines, and
to analyze the reason of an eventual prophylaxis underuse in these
populations of patients. Patients were considered at risk for bleeding, and for this reason not eligible for an anticoagulant prophylaxis, if they present with or developed during hospitalisation any
of the following: intracranial haemorrhage, hepatic impairment,
Medicina d’Urgenza, PTV – Dipartimento di Medicina Interna, Università di Tor Vergata
37
proceedings
bleeding at hospital admission, gastroduodenal ulcer, thrombocytopenia. Of the 436 patients admitted into our department
between January and September 2009, 283 patients met the criteria of the 2008 ACCP guideline recommendations. In total 155 patients (55%) received pharmacologic VTE prophylaxis. These data
are consistent with previous studies. The prophylaxis was carried
in 75% of patients with congestive heart failure, 67% with respiratory failure, 55% with immobility ≥ 3 days, 100% with prior VTE,
52% with cancer, 52% with sepsis. When two or more VTE risk
factor were present 63% of patients received ACCP recommended
prophylaxis even if one bleeding risk was present. In our study
122 patients (43%) were considered to have a sufficient risk for
bleeding to present a contraindication to anticoagulant prophylaxis, even though one half of these patients received prophylaxis. The type of bleeding risk and not its simple presence have
had a role in the decision to provide VTE prophylaxis; excluded
from prophylaxis: platelet count < 50000, ICH, INR > 2, active
bleeding, esophageal varices F3. Only few patients without risk
factor for bleeding not received prophylaxis. Our data show that
a large proportion of acutely ill hospitalized medical patients
are at risk for VTE and that recommended VTE prophylaxis is
underused not for a lack of awareness of the evidence based
guidelines, but for the presence in the same patient of one or
more bleeding risk; in this patients subset guidelines are not clear.
The anti-coagulant oral therapy and his complications.The
effects on the Policlinico’s Emergency Department in Tor
Vergata
Verga V., Forte E., Brandi A., Giovagnoli G., Santucci L., Legramante J.M., Galante A.
38
Medicina d’ Urgenza, PTV Dipartimento di Medicina Interna, Universita’ di Tor Vergata
The increase of number of patients treated with oral anti-coagulants drugs in Italy, as well as in many other world countries,
has determined an increase of their side effects leading to an increase of hospitalizations, huge use of Emergency Departments
(ED) and consequently increase of the costs of the entire Health
System.
The aim of our research is to estimate this phenomenon from a
particular point of view represented by the Policlinico’s Emergency Department in Tor Vergata in order to consider the impact on
it, during the period between January 2006 and December 2007.
The total number of patients treated by our Emergency Room,
during the above mentioned period, has been 98570. Among
them, 137 patients (0.13% of the interested population) have
been included in this research to have a countercheck of the
INR>5 values. The analysis has been conducted dividing the
people according to sex (51.8% males and 48.8% females), age
(45.2% of them were belonging to a range between 75 and 89
years), acceptance code (59.1% were yellow code, 34.3% were
green, 5.8% were red and 0.7% white), INR’s values at the beginning (54% of them reported values between 5 and 6.9), indicators
of the anticoagulant oral therapy (51.8% of them were suffering
FA), kind of consumed medicine (51.8% of them were consuming sintrom), eventual kind of haemorrhage (30.6% of the patients were going to the ED because of haemorrhages and among
them 22.7% for gastrointestinal ones, 21.4% for haematomas,
16.6% for haematuria, 10% for brain haemorrhage, 10% for epistaxis, 10% for ecchymosis, 6.8% for gingival problems, 4.7% for
haemoptysis, 2.3% for conjunctival haemorrhage), administered
therapy (mostly konakion), outcome at discharge (most of them
were hospitalized again), admission’s date (the most crowded
month has been August).
From our estimate, it appears clear and needs an afterthought the
fact that the number of patients that, thought haematochemical
exams, have got INR>5 values, represented an important/huge
portion of all Policlinico’s First Aid Department’s users during the
considered period (p=0.00001). Furthermore, among all patients,
those who really needed a prompt intervention, with assigned red
code, has been those with INR>5 values without clearly haemorrhagic development (p=0.01203).
The experience gained inside the Emergency Department and the
data analysis allow us to state that, for the majority of the observed patients, a good and correct health education, a good check
(including indications and contraindications to the therapy, the
elapsed therapeutical time, the good management of the intercurrent illnesses), a medium and discrete knowledge of the patient’s
skills, an accurate and serious anamnestic collection, could reduce the risk of complications that would also mean a less waste of
resources and efforts for the entire Health System.
Neodiagnosis of cancer in Emergency Room: three years of
observation in the Emergency Department of Policlinico
Tor Vergata
Tamburri R., Legramante J.M., Gallù M., Minetola L., Galante A.
Medicina d’Urgenza, Policlinico Tor Vergata, Dipartimento di Medicina Interna, Università Tor Vergata, Roma
Cancer is one disease which produces more worry all over the
world since it causes worsening of life quality and weighs heavily on population’s premature mortality besides requiring a lot
of resource investment to allow the diagnosis and promote the
treatment of patients.
The aim of the present study was to evaluate patients who refer
to the Emergency Room of Policlinico Tor Vergata (PTV) from
January 2005 to December 2007 and were discharge with a new
diagnosis of cancer.
We enrolled 332 oncologic patients who were diagnosed in PTV
ED from 2005 to 2007. Most of patients belong to cluster who
were 75-79 years hold or 70-74 years hold. Both patient with
12% died during the recovery, 6,4% were admitted in different
structures (only 9 were admitted in Hospice).
The study shows how Emergency Department is a privileged
observatory which allows to estimate the efficiency of the oncologic screenings plans. Prevention and precocious diagnosis had
drastically reduced the numbers of admittance in Emergency
Department for patients who show disease diffusion. It’s extremely important to sensitize the whole population in screening
plans for a prompt diagnostic strategy which allow an early cancer diagnosis. Unfortunately, our results show that too frequently the first diagnosis of cancer is done too late as compared to
the cancer exordium. The missing diagnostic timeliness reveals both the lack of valid and sensible instruments which can
discover some kind of cancer, which are available only during
hospitalization regimen and the failure of Territory Medicine
which seems to be inattentive and inadequate when it has to
face oncologic disease.
Study of cardiovascular autonomic regulation during early
phase of acute myocardial infarction: an experimental
model in conscious, freely moving rats
Crobeddu P., Sacco S., Pallante M., Galante A., Legramante J.M.
Medicina d’ Urgenza, PTV Dipartimento di Medicina Interna, Universita’ di Tor Vergata
Ischemic heart disease includes illnesses with different etiology. These have in common the imbalance between demand and
supply of oxygen to the myocardium. One of the most frequent
clinical expression of ischemic heart disease is the myocardial infarction which is caused by myocardial ischemia inducing cell
necrosis. During myocardial infarction an alteration of the Autonomic Nervous System occurs, in particular of the Arterial baroreflex System.
Therefore there is an increased activity of the Sympathetic Nervous
System associated with a reduced functionality of the Parasympathetic Nervous System. It has been widely reported that the Baroreflex sensitivity is reduced after acute myocardial infarction and this
reduction represents an adverse prognostic significance.
Currently few studies describe these mechanism during the early
phases of Acute Myocardial Infarction (IMA)in vivo. Therefore
the aim of the present study was to evaluate the feasibility of the
cardiovascular autonomic study in the early phase after IMA and
to report preliminary data. The technique of spontaneous sequences allow the study of the autonomic cardiovascular regulation in a noninvasive and nonobtrusive way. The total study have
been performed on 11 rats of both sexes (8 in the IMA group and
3 in the control group). Eight rats were part of the myocardial
infarction group, three rats were part of the control group.
Our team implants a transducer in the abdominal aorta to continuously record blood pressure. From the blood pressure time
series calculation of baroreflex and non-baroreflex sequences is
performed as expression, respectively, of negative and positive feedback neural mechanisms of cardiovascular regulation.
The myocardial infarction have been induced by cauterization
of the left anterior descending coronary artery. Preliminary data
show an increase in the occurrence of baroreflex sequences along
the 24 h both in the IMA and in the control group (from 91 in
control condition to 120 after 24 h for IMA group and from 63 in
control condition to 125 after 24 h for the control group). This
increased baroreflex engagement is related to a reduced baroreflex sensitivity (BRS) in the IMA group (from 3.3 msec/mmHg in
control condition to 1.9 msec/mmHg after 24 h) but not in the
control group (from 3.3 msec/mmHg in control condition to 3.0
msec/mmHg after 24 h).
Nonbaroreflex sequences show no substantial changes along the
24 h in the IMA group (from 37 to 43) whereas a trend to decrease is evident for control group (from 39 to 16). Similarly to BRS
the sensitivity of nonbaroreflex sequences shows a trend to decrease fro IMA group (from 3.2 msec/mmHg to 1.8 msec/mmHg
after 24 h) whereas no substantial changes are evident in the control group (from 4.7 msec/mmHg to 3.6 msec/mmHg).
According these preliminary data, instability of the cardiovascular system seems to occur after the experimentally-induced
IMA. We see an increase in the baroreflex engagement with a
corresponding trend to BRS decrease after IMA as compared to
control animals. Even though the small sample reported in this
preliminary report need to be increased in order to have more
definite results, we can suggest that this first demonstration of a
BRS decrease in the first 24 h after IMA add a pathophysiological
mechanisms supporting the widely reported increased risk for life
threatening arrhythmias in the first hours after IMA.
underhand clinical symptoms (asthenia, abdominal pain) and
patients who present more important symptoms (Thoracic pain,
gastroenteric bleedings) indifferently referred to ED, which is deputed to manage the emergency. According to the site the most
frequent cancer diagnosed in ED were: the Gastroenteric. Breast,
hemopoietic and Reproductive System cancer were not represented in our sample. This difference maybe justified by different
way of hospital admission for this kind of patients for which the
diagnostic suspect comes out during ambulatory visits or in day
hospital regimen. For 169 pts the cancer was discovered during
the recovery in the Emergency Department, that was, in average,
2 days for patients who have medical problems and 4 days for patients with surgical one’s. 179 pz (54%) undergone a specific surgical operation, 153 (46%) undergone only a medical treatment
in Medical Divisions, both Internal Medicine and Specialistic. No
one patient was enrolled in a chemiotherapic treatments. At the
end of hospitalization 78% of patients was discharged at home,
proceedings
39
proceedings
Early versus Late Recurrence of Panic Attack in the
Francesco Buccelletti, Davide Marsiliani, Annarita Carroccia, Emanuele Gilardi, Giuseppe Merra, Nicolò Gentiloni
Silveri, Francesco Franceschi
Department of Emergency Medicine, Catholic University of the Sacred Heart, Rome – Italy
40
Introduction
Panic Attack Disorder (PAD) is a very common diagnosis in the
Emergency Department (ED). Although it is a benign disease in
terms of mortality, recurrence is almost the rule and therefore it
represents an economic burden [1]. Moreover, PAD often mimic
more serious conditions such acute coronary syndrome and the
work-up in the ED might be expensive, long and difficult [2]. There are programs and tools in the ED to screen for PAD but none is
validated and recognized as gold standard [3]. Identifying patients
at high risk for early recurrence (i.e. within 90 days) might help
to plan education treatment for PAD preventing further ED visits.
This study investigated clinical characteristics of patients diagnosed with PAD in ED with recurrence within 90 days.
Materials and Methods
ED electronic database, GIPSE® (Public Health Agency, Italy)
was searched for patients discharged or admitted with primary
ICD-9 diagnosis of panic attack, from 2001 to 2006 in a tertiary care, university, hospital. Exclusion criteria were age <18 and
acute coronary syndrome. Search was performed between January 2001 and December 2006. All selected patients were tracked
for recurrence until December 2009 (at least 3 year of followup). Charts were manually extracted in a dedicated database
and blindly reviewed by two authors (FB and DM) for diagnosis
accuracy. Cohort was then divided into “early recurrence” (i.e.
patients who presented for PAD a second time within 90 days)
and “late recurrence” (patients who experienced a second attack
and visit in more than 90 days). The two groups were compared
for demographics, symptoms patterns and intervention received
(pharmacologic treatment and psychiatry consult) using logistic
regression with a forward likelihood (inclusion and exclusion thresholds respectively 0.05 and 0.1) to improve model fitting and
to select only significant variables. P values <0.05 were conside-
red significant.
Results
One-thousand-three-hundreds-one (1301) patients had a primary diagnosis of PAD and met inclusion/exclusion criteria. 214
patients (16.5%) had at least a recurrence in the next 3 years.
Median time for recurrence was 6.5 months. 31.8% of the patients had more than one recurrence. 59 patients (27.2%) had a
recurrence within 90 days (early recurrence). Table 1 summarizes demographics and clinical characteristics. Logistic regression
including predictors shown in table 1 identified age (OR 0.80
[0.65-0.98]) and shortness of breath at presentation (OR 0.47
[0.22-1.00]) as the only significant factors associated with early
recurrence (omnibus model test p=0.016). Intervention such treatment with benzodiazepines and psychiatry consult performed
in the ED were not significant (p=0.11 and 0.88 respectively).
The most important limits of this study were: single hospital and
a possible underpower issue since panic attacks are often diagnosed with alternative codifications (i.e. unspecific chest pain etc.).
Conclusions
PAD is common in the ED because symptoms at presentation mimic more serious conditions. Despite a precise diagnosis is made,
patients presents to the ED with recurrence in a high percentage
of cases (within 6.5 months in 50% of the cases). Patients who
experience a new ED access within 90 days are generally younger
(<40 year old) and experienced shortness of breath as chief complain compared to those who returned to the ED later in time.
This group might require a specific and more aggressive intervention in terms of education and medical/psychological referral.
Even though we cannot exclude to be underpowered, psychiatric
consult in the ED did not seem to prevent early recurrence.
Table 1 - Demographics and clinical characteristics of PAD
Early Recurrence (N=59)
Age
Late Recurrence (N=155)
Univariate P-Value
35 (12)
41 (14)
0.05
Female
34 (57.6)
92 (59.4)
0.81
Shortness of Breath
10 (16.9)
33 (21.3)
0.44
Chest Pain
7 (11.9)
22 (14.2)
0.67
Palpitations
12 (20.3)
33 (21.3)
0.88
Self Reported Anxiety
23 (39.0)
56 (36.1)
0.75
Tremors
Headache
16 (27.1)
2 (3.4)
42 (27.1)
10 (6.5)
0.99
0.38
Pharmacologic treatment in ED
34 (57.6)
74 (47.7)
0.19
Psychiatric Consult in ED
11 (18.6)
21 (18.1)
0.91
All cells are numbers (%) except age expressed as mean (standard deviation). Univariate P-values are based on chi-squared test except
for age (Mann-Whitney U test).
References
1 Coley KC, Saul MI, Seybert AL. Economic burden of not recognizing panic disorder in the emergency department. J emerg
Med 2009: 3-7.
2. Koeczac DJ, Goldstein BI and Levitt AJ. Panic disorder, cardiac
diagnosis and emergency department utilization in an epidemiologic community sample. Gen Hosp Psychiatry, 2007: 335-339.
3. Pelland ME, Marchand A, Lassard, MJ et al. Efficacy of 2 interventions for panic disorder in patients presenting to the ED with
chest pain. Am J Emerg Med, 2010: E-Pub Sept 24.
proceedings
Clinical Presentation, Microbiological Features And
Correlates Of Disease Severity Of 2009 Pandemic
Influenza A (H1n1) Infection
S. Farina1, L. Zileri Dal Verme2, M. Sabbatini2, D. Marsiliani2, G. Pignataro2, L. Carbone2, M. Candelli2, P. Tilli2, S. Di
Giambenedetto1, N. Gentiloni Silveri2
Purpose
To describe epidemiological, clinical and microbiological characteristics of confirmed novel influenza A (H1N1) infection, investigating factors associated to disease severity.
Methods
We retrospectively selected patients seeking care for respiratory
symptoms in two periods (May-August and September-November 2009) with different epidemiological characteristics. Only
patients with swine-origin influenza A (H1N1) detected from
respiratory specimens by RT-PCR assay were considered for this
analysis.
compared to those aged 15-39 (p=0.008) or to those under 14
years (p=0.006). Clinical signs, symptoms and respiratory complications seemed to differ between the two study periods. On
the total, 18 patients (17%) had pneumonia. A pneumonia diagnosis was more frequent in the second period (37% versus 10%,
p=0.002). Patients older than 50 years showed a lower probability of pneumonia diagnosis when compared to children aged
0-13 (p=0.049); a longer duration of symptoms before medical
care was associated with a higher probability of pneumonia
(p=0.026). Phylogenetic analysis showed a low variability both in
hemagglutinin and neuraminidase genes. In addition, no neuraminidase mutation associated to antiviral resistance was detected.
Results
A total of 104 patients with H1N1 infection were evaluated.
Subjects mostly complained of classic influenza symptoms; in
addition, diarrhea and vomiting were often referred. The hospitalization rate was higher in patients older than 40 years when
Conclusions
A detailed description of respiratory diseases associated with
H1N1 infection was provided and factors associated with its severity were investigated, thus contributing to the insight into epidemiological, clinical and microbiological knowledge of the disease.
Left Ventricle ultrasound evaluation agreement between
different expertise operators in Emergency Department
Pivetta E1,2, Balcet L3, Lorenzati B4, Esposito G5, Di Bella S6, Laurita E2, Goffi A7, Cibinel GA2
Cancer Epidemiology Unit and Piedmont Oncology Prevention Center, AOU S. Giovanni Battista - Turin, and University of Turin;
Emergency Medicine Department – “E. Agnelli” General Hospital – Pinerolo, Torino;
3
Geriatrics and bone metabolic diseases, AOU S. Giovanni Battista – Turin, School of Specialization in Geriatrics, University of Turin;
4
General Medicine 3, AOU S. Giovanni Battista – Turin, School of Specialization in Internal Medicine, University of Turin;
5
V division of Internal Medicine and Immunoallergology, School of Specialization in Internal Medicine, II University of Naples;
6
Geriatrics and bone metabolic diseases, AOU S. Giovanni Battista – Torino, School of Specialization in Internal Medicine, University of Turin;
7
Critical Care Medicine Department, Saint Michael’s Hospital, Toronto, Ontario, Canada
1
2
Introduction
First level ultrasound evaluation (US) is often used in Emergency Medicine Department (ED) as a diagnostic tool in chest,
abdomen, venous and heart examination. A recent study has highlighted a high agreement in the evaluation of the left ventricle
function between intensivists inexpert in echocardiography and
expert echocardiographists.
Objectives
The aim of this study is to evaluate the agreement between inex-
pert operators and a single expert echocardiographist (used as reference) in evaluating the left ventricle function and the ejection
fraction in ED.
Methods
Medical resident physicians have been involved as inexpert US
operators: at the moment of the study their only experience consist in participation in an advanced US course (9 hours of theoretical and practical echocardiography).
Patients evaluated in Pinerolo General Hospital ED, triage codi-
1
Institute of Clinical Infectious Diseases, Catholic University of Sacred Heart; 2Department of Emergency Medicine, Catholic University of Sacred
Heart
41
proceedings
fied as green or yellow, were recruited if presenting with syncope,
acute dyspnoea, chest pain or palpitations.
We collected demographic and clinical data for each patient,
including ED evaluation cause, medical history, physical examination, EKG, chest X-ray evaluation, details on US evaluation
(echocardiography, possible compression vein US, lung US and
evaluation of inferior cava vein (ICV)) provided by resident physician and by an expert operator, an emergency physician and a
cardiologist with a level 3 American Heart Association expertise.
Cohen’s kappa was used as the agreement measurement for each
US variable.
Results
At this time, 23 patients have been enrolled: 9 women (39.1%)
and 14 men (60.9%). Median age was 85 years (range 78-97 years) and 73 years (range 60-100), respectively. 4 patients were
positive for chronic obstructive pulmonari disease, 6 for ische-
mic cardiopathy, 5 for cardiomiopathy and 7 for hypertensive
cardiopathy. ED evaluation causes were: syncope in 5 cases, acute
dyspnoea in 14, chest pain in 3 and palpitations in 1 case. The expert operator categorized 13 US evaluation as “low complexity”,
1 as “medium”, and 4 as “high”. Cohen’s kappa was 0.62 for left
ventricle evaluation (categorized as “normal” or “dilated/hypokinetic”), 0.51 for estimated ejection fraction (“normal”, “small/
moderate/large reduction”) and 0.86 for ICV dimensions evaluation (“normal” or “dilated”).
Conclusions
Our study found a moderate agreement between inexpert operators and a reference echocardiographist in evaluating left ventricle function and ejection fraction in ED. We expect to find an increased agreement in learning curves for each inexpert operators
as the number of evaluations increases. Finally, we found a high
agreement for ICV dimensions evaluation.
Lung Ultrasound for acute dyspnoea in Emergency
Department – a multicenter study protocol
42
Pivetta E1,2, Goffi A3, Baldi I1, Lupia E4, Ciccone G1, Cibinel GA2, Merletti F1
Cancer Epidemiology Unit and Piedmont Oncology Prevention Center, AOU S.Giovanni Battista - Turin, and University of Turin;
Emergency Medicine Department – “E. Agnelli” General Hospital – Pinerolo, Turin;
Critical Care Medicine Department, Saint Michael’s Hospital, Toronto, Ontario, Canada;
4
General Medicine 5, AOU S.Giovanni Battista – Turin and University of Turin
1
2
3
Introduction
Dyspnoea is one of the most frequent symptoms in patients evaluated in Emergency Departments (ED) and yet often difficult to
interpret by emergency physicians. Early and accurated differential diagnosis is essential for efficacious therapy. Several studies
have assessed the utility of ultrasound (US) for dispnoic patient
evaluation. Lung US has proven to have good accuracy and reproducibility, although estimates show large variability due to the
different reference used (i.e. lung x-ray, lung computed tomography, an expert physician…) and to the small number of cases.
Objectives
The aim of this study is to describe the protocol for the evaluation
of accuracy and diagnostic impact of lung US performed by emergency physicians to identify interstitial syndrome and pleural effusion as US signs of cardiogenic dyspnoea. The reference will be
the “a posteriori” diagnosis by a panel of expert emergency physicians. The protocol was approved by the Ethical Commitee of
the AOU San Giovanni Battista in Turin, and has been submitted
for registration on clinicaltrials.gov.
Moreover, the study will evaluate reproducibility between operators in interpreting US images and will define a clinical-US flow
chart for acute dyspnoea management in ED.
Methods
The design of this study is a multicenter prospectic cohort, with a
six months recruitment period in each center. Adult patients will
be considered eligible if they refer acute dyspnoea, an emergency
physician with lung US experience is present, and US examination is possible within 30 minutes after the start of the clinical
evaluation. Dyspnoea cases clearly due to neither cardiogenic nor
respiratory ethiology will considered not eligible.
After the initial diagnostic work-out (medical history, physical
examination, EKG, arterious blood gas), the emergency physician will classify dyspnoea in cardiogenic or respiratory dyspnoea
and write it down in a specific form (clinical form). Immediately
after this, lung US will be performed: the physician will describe
it and evaluate the etiology again (integrated evaluation form).
Then a chest X-ray evaluation will be performed for each patient.
A final diagnosis (“a posteriori” form) will be determined after
discharge by a panel of expert emergency physicians using all
available information.
Patients will be investigated in supine or semi-recumbent position, following a scanning protocol modified by Volpicelli et al.
[Bedside lung ultrasound in the assessment of alveolar-interstitial syndrome. American Journal of Emergency Medicine, 2006.
24(6)] in which eight zones of the lungs are scanned.
The study intends to recruit 1000 patients. Such a study sample
size will allow us to test absolute differences of 10% in sensitivity
and specificity between standard and US-integrated evaluation,
with 90% study power and 5% alpha (two-samples test), assuming: a cardiogenic dyspnoea prevalence in the cohort ranging
from 45% to 55%, and traditional evaluation sensitivity and specificity ranging from 70% to 85% and from 75% to 85%, respectively.
A pilot study is ongoig to test feasibility and the data collection
tools. Recruitment for the main study is planned to start on November, 2010, with a one-year estimated study duration, and the
involvement of six EDs.
Conclusions
The study will define lung US sensitiviy, specificity, positive and
negative predictive values in the identification of interstitial syndrome and pleural effusion; positive and negative likelihood
ratios to determine how diagnosis probability may change with
lung US result; the impact of US diagnostics. Furthermore it will
be possible to assess inter-observer agreement in interpreting US
images (expert vs inexpert, blinded evaluations). Furher analyses
will be perfomed by subgroups for other tests regularly used in
dyspnoea diagnosis (i.e. BNP dosage).
A “double-coding triage system” to re-organize the patient
pathways in the Emergency Department: the experience of
an Italian Hospital
proceedings
Mana E1, Civita M1, Sfasciamuro C1, Goffi A2, Odetto C1, Pivetta E1,3, Cibinel GA1
Emergency Medicine Department – “E. Agnelli” General Hospital – Pinerolo, Turin;
Critical Care Medicine Department, Saint Michael’s Hospital, Toronto, Ontario, Canada;
3
Cancer Epidemiology Unit and Piedmont Oncology Prevention Center, AOU S. Giovanni Battista - Turin, and University of Turin
1
2
Objectives
The aim of this study was to evaluate waiting time (WT) for medical examination with the new 6-codes based triage system in a
first level general hospital ED.
Methods
The numerical code stratifies patients in four different categories according to the potential rapidity of clinical deterioration on
the basis of clinical signs and symptoms: 4) immediate threat to
life and/or severe alteration of at least one of four specific vital
signs, 3) remarkable risk of short-term alteration of vital signs 2)
low-risk of short-term alteration of vital signs 1) no alterations
of vital signs.
The triage steps are: first evaluation (taking vital signs), second
evaluation (general suffering signs, pain intensity, bleeding, vomiting, temperature, primary specific signs, related to the main
symptom, and secondary specific signs, indirectly related to the
main symptom, i.e. allergy, medicaments, history of past illness,
last meal, age, risk factors...), code definition and continuous reevaluation (no re-evaluation for 4 red but immediate medical evaluation, after 5 minutes for 3 yellow, after 10 minutes for 2 yellow,
after 45 minutes for 2 green, after 90 minutes for 1 green, after
240 minutes for 1 white).
The double-coding triage system was applied to all patients during the first trimester of 2008.
Results
With the new triage system the WT decreased from 48 to 14 minutes for 3 yellow, from 49 to 15 for 2 yellow, from 60 to 38 for
2 green, whereas it increased from 50 to 55 for 1 green and from
76 to 95 for 1 white.
The analysis of data led to the re-organization of the patient pathways in the ED: before the study, our ED was organized in three
different working lines, differentiating patients having surgical
issues (one dedicated medical doctor, MD), medical issues (two
dedicated MDs) and patients with low severity codes (green and
white – one dedicated MDs). After this study, a four pathways system has been introduced in the daily clinical practise of the ED,
as follows: two pathways for newly admitted patients with high
priority code (3 - 2 Yellow and 2 Green), one pathway for patients
admitted to the ED during the previous clinical shift (each shift
lasting 6.30 or 12 hrs) and for patients requiring immediate assessment (4 red), and finally one pathway for patients with low
priority codes (1 Green and 1 White). This last pathway runs
only during daytime (8 a.m.- 8 p.m.).
Conclusions
Overall, the new triage system resulted in a significant reduction
of the WT for patients with high priority codes and just a moderate WT increase for low priority codes.
This study found that the implementation of a procedural reorganization of the ED may result in a more efficient health service,
even if further investigations are needed to define better the potential impact of this novel system on patient care.
Utility Of A Multimarkers Approach In The Diagnosis And
Prognostic Stratification Of Patients With Chest Pain In
Valerio Pittoni M.D., Emiliano Salvatori M.D., Gabriele Tavani M.D., Salvatore Di Somma M.D.
Department of Emergency Medicine, S. Andrea Hospital, La Sapienza University, Rome-Italy
Introduction
The evaluation of patients with acute chest pain in Emergency
Department (ED) is often a diagnostic challenge to physicians.
Undetected acute coronary syndrome (ACS) remains a serious
public health issue and represents a major cause of malpractise
in the emergency setting. A common work up in these patients’
evaluation includes clinical history, physical examination, ECG,
laboratory tests. Most widely accepted are the WHO criteria for
ACS diagnosis which comprises ECG evidence, symptoms of
chest discomfort, biochemical evidence (myocardial necrosis/
ischemia markers). The measurement of troponins have helped to shorten and improve the diagnostic workup. Strategies
combining troponin measurement with already known such as
myoglobine or CKMB or newly discovered markers remains to
be elucidated.
The aim of the study is to evaluate the use a of point-of-care
measurement of a combined panel of four markers: troponin I,
CKMB, Myoglobine, BNP (Triage Point of Care Triage POCT Biosite, San Diego USA), in patients admitted to ED for chest pain.
Introduction
As stated by the Italian law, the priority of admission to the Emergency Department (ED) is triaged according to a colour code that
can be red, yellow, green, and white, in descending order of priority. This system allows the stratification of patients on the basis
of the main complaints. After a careful review of the procedural
protocols and an adequate training of the nurses, as established
by the Italian law n°43-15182 of 23/03/05, a new triage system
has been developed in the ED of the Pinerolo General Hospital. It
results in the combination of a numerical code with the previous
and more traditional 4-colour code.
43
proceedings
Patients & Methods
523 patients referring to ED for chest pain have been enrolled (in
our ED and in “Vittorio Emanuele Hospital” of Catania (Italy),
“Hospital de la Santa Creu i Sant Pau” of Barcellona (Spain), and “
Emergency Department University Hospital” of Jena (Germany),
from April 2008 to November 2009), 323 Men, 179 Women,
mean age 64 (±14) yrs. 18 patients have been excluded, 6 due to
enrollment exclusion criteria and 12 because diagnosis was missing. We performed at arrival in ED anamnestic data, TIMI risk
score, physical examination, ECG 12 leads, chest X-ray and blood
tests analyzed by POC system at the admission (T0) and after two
hours (T1) for BNP, TnI, CK-MB and Myoglobin.
Results
First draw BNP for prediction UA showed the most significative
AUC (0.613 ± 0.074): BNP 20 pg/ml cut-off has best odds ratio
(3.64, p-value < 0.0001. The sensitivity and specificity for diagnosis of UA improves when we combine BNP (0 hr) + TIMI +
TnI(2 hr).
The same model showed the most significative AUC (0.751±
0.094) in the prognostic stratification for major cardiac events
at 30 days.
Conclusions
Our data show that baseline sample of BNP seems to be a better
predictor of UA than CK-MB, TnI and Myoglobin.(the cut-off 20
pg/ml is superior than 80pg/ml and 200 pg/ml) and of major cardiac events at 30 days from discharged. Moreover the diagnostic
value of BNP improve in association with TnI and TIMI score.
Serum procalcitonin and S.Viridans endocarditis: case
report
Buccelletti F., Zileri dal Verme L., Marsiliani D, Carroccia A., Merra G.,Gilardi E., Calcinaro S., Franceschi F.,
Gentiloni Silveri N.
Department of Emergency Medicine, Catholic University of the Sacred Heart, Rome – Italy
Introduction
Procalcytonin (PCT) is considered a biomarker sensitive and specific for bacterial infection [1]. It is particularly useful in the differential diagnosis of undifferentiated dyspnoea in the Emergency
Department (ED) and it has been proposed as guide in severe
sepsis/septic shock treatment and prognosis [2;3]. Although its
high sensitivity and specificity, in literature certain classes of pathogens do not elevate PCT.
Clinical case
A 67 year old male, affected by coronary artery disease, hypertension, paroxysmal atrial fibrillation and previous cholecystectomy
presented to the ED complaining of one-month fever and sweating. During his out-of-hospital work-up a cardiac ultrasound
was performed showing a medium aortic valve insufficiency and
no vegetations.
Patient was admitted to the hospital for immunological and
rheumatic workup together with serology for viruses. PCT was
measured 3 times all times along with blood cultures. PCT was
negative in all determinations while Streptococcus Viridans was
isolated in the blood..
After this last data a new echocardiogram was performed, which
showed a lesion of anterior aortic cusped; lesion confirmed by a
transesophageal echocardiogram.
Discussion
PCT is a relatively new marker and for this reason we do not
know all its characteristics. In fact in a brief report of Cuculi et
all: “Serum Procalcitonin has the potential to identify S.Aureus
endocarditis” [4] PCT is not able to identify an infection from
Streptococcus Viridans but at the same time it has optimal results with Staphylococcus Aureus. Our case confirmed previous
observations in a endocarditis. This issue needs to be considered
when PCT is ordered and results interpreted. The reason why Str.
Viridans do not alter PCT is unknown.
Conclusions
Normal levels of PCT are not a sufficient data to rule out the
patient from the diagnosis of a bacterial infection in the setting of
Streptococcus Viridans infetion.
References
1) Whang KT, Steinwald PM, White JC, Nylen ES, Snider RH,
Simon GL, Goldberg RL, Becker KL Serum calcitonin precursors
in sepsis and systemic inflammation. J Clin Endocrinol Metab
83(9):3296–3301 (1998).
2) Mueller C, Huber P, Laifer G, Mueller B, Perruchoud AP
(2004) Procalcitonin and the early diagnosis of infective endocarditis. Circulation 109(14):1707–1710 (2004).
3) Tang BM, Eslick GD, Craig JC, McLean AS Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis. Lancet Infect Dis 7 (3):210–217, (2007).
4) Cuculi F, Toggweiler S, Auer M, der Maur ChA, Zuber M, Erne
P. “Serum procalcitonin has the potential to identify Staphylococcus aureus endocarditis”. Eur J Clin Microbiol Infect Dis. 2008
Nov;27(11):1145-9. Epub 2008 Jun 3.
44
Analisi Epidemiologica Degli Accessi Per Dolore
Addominale Acuto Non Traumatico In Abruzzo:
Valutazione Della Conformita’ Della Diagnosi Tra P.S. E
Reparto
proceedings
E., Varrato¹, G. Cretara¹, A. Melone², S. Sofia³, R. Di Filippo C. Balsano*
Negli Stati Uniti ogni anno accedono ai Dipartimenti di Emergenza/Urgenza 5 milioni di persone per dolore addominale acuto. La
percentuale di ricovero varia dal 18% al 42%. È interessante notare come al momento dell’accesso in P.S. dal 5 al 10% dei pazienti
presenti già le complicanze.
L’eziopatogenesi del dolore addominale acuto rimane misconosciuta in oltre il 30% dei casi; infatti, la causa più comune è
rappresentata dal “dolore addominale non specifico” (dal 24 al
44,3%), seguita dall’appendicite acuta (15.9 - 28.1 %), dalla patologia biliare acuta (2.9 - 9.7 %) ed, infine, dall’ostruzione intestinale e dalla diverticolite.
In Italia, ed in particolare nella regione Abruzzo, non esistono
dati statistici relativi agli accessi in P.S. e ai ricoveri per dolore
addominale acuto non traumatico.
Il nostro gruppo intende condurre uno studio osservazionale
sui pazienti con addome acuto, che accedono ai Dipartimenti di
Medicina di Emergenza/Urgenza sottoriportati, in modo da determinare l’epidemiologia relativa alla Regione Abruzzo e stilare le raccomandazioni per l’istituzione di percorsi diagnosticoterapeutici-assistenziali e di profili integrati di cura nelle Aziende
Sanitarie della Regione Abruzzo.
Inoltre, visto che il quadro clinico del dolore addominale richiede
una grande esperienza e capacità di giudizio nell’interpretazione
dei segni, il secondo obiettivo sarà quello di verificare se l’utilizzo
dell’ecografia in emergenza da parte del clinico possa migliorare
l’accuratezza diagnostica della prima valutazione in Pronto Soccorso rispetto alla diagnosi di dimissione dal reparto.
Lo studio verrà effettuato nei Presidi Ospedalieri sotto elencati:
Unità Operativa di Emergenza-Urgenza del P.O. di Teramo
Unità Operativa di Emergenza-Urgenza del P.O. di Avezzano
Unità Operativa di Emergenza-Urgenza del P.O. dell’Aquila
Tra gennaio 2011 e gennaio 2012 si valuterà il numero di accessi
totale per dolore addominale acuto, si stratificherà il campione di
popolazione in relazione alla casistica etiologica osservata ed in
rapporto all’età dei pazienti. Verrà, quindi, valutata la conformità
della diagnosi effettuata in P.S. rispetto a quella formulata in reparto di degenza.
Bibliografia
ACEP, Emergency Ultrasound Guidelines, Ann Emerg Med.
2009; 53:550-570.
ACEP, Clinical Policy: Critical Issues for the Initial Evaluation
and Management of Patients Presenting With a Chief Complaint
of Nontraumatic Acute Abdominal Pain, Ann Emerg Med. October 2000; 36:406-415.
Lameris W et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy
study. BMJ2009:b2431.
Hastings RS, Powers RD., Abdominal pain in the ED: a 35 year
retrospective. Am J Emerg Med. 2010 Apr 30.
Grundmann RT, Petersen M, Lippert H, Meyer F., The acute (surgical) abdomen - epidemiology, diagnosis and general principles
of management, Z Gastroenterol. 2010 Jun;48(6):696-706. Epub
2010 Jun 1.
Prognostic value and therapeutic implications of
Hyperdensity Middle Cerebral Artery Sign (HMCAS) in
hyperacute ischemic stroke
F. Biraschi, F. Di Lisi, A. Romano, A. Bozzao, L. Fantozzi, M. Rasura
Dipartimento Neuroscienze/Stroke Unit – Neuroradiologia Ospedale Sant’Andrea/Sapienza II facoltà di Medicina – Roma
Objectives
Aim of our study is to evaluate patients with evidence of HMCAS
at CT multi-detector performed within the 6 hours from stroke
onset by analyzing neuroimaging and clinical features in order to
assess the prognostic value of HMCAS, site of HMCAS and possible therapeutic implications.
Methods
We retrospectively reviewed the records of 41 patients admitted
to our Emergency Room with the diagnosis ischemic stroke in the
vascular territory of the MCA within 6 hours after the symptoms onset. We evaluated CT scan, determinated the site of the hyperdense
middle cerebral artery sign (HMCAS), performed the Alberta Stroke
Program Early CT Score (ASPECTS) on MRI at 24 hours to the onset. Baseline clinical characteristics were analyzed with the NIHSS at
the admission, risk factors, stroke aetiology and therapeutic measures. Clinical outcome was evaluated with 3 months modified Rankin
Scale (mRS). According to the site of HMCAS we identified three
groups: proximal (M1), middle (M2), distal (M3). For each group
we correlated the average ASPECTS with NIHSS at the admission
and 3 months mRS. Further analysis was performed for the subgroup of patients who underwent to intravenous thrombolysis.
Results
We identified 15 (36.6%) patients with M1 hyperdensity, 14
(34.1%) patients with M2 hyperdensity and 12 (29.3%) patients
¹U.O. di Medicina Interna, P.O. “ G.Mazzini” di Teramo;
³U.O. di Medicina Interna, P.O. U.O. di “Santissima Maria dello Splendore” di Giulianova, Medicina Interna, P.O. “S. Salvatore” dell’Aquila;
*Dipartimento di Medicina Interna e Sanità Pubblica, Università degli studi dell’Aquila
45
proceedings
with M3 (“dot sign”) hyperdensity. Baseline characteristics do not
show significant differences among the 3 groups. Mean NIHSS at the
admission among the three groups was 15.2 in M1, 10.4 in M2 and
6.8 M3 group (p 0.001). The ASPECTS average in the three groups
was M1 4.8, M2 6.5, M3 7.0 (p 0.006). In logistic regression analysis
the HMCAS is independently associated with an unfavorable outcome (modified Rankin Scale mRS> 2) at 3 months. However average
mRS shown significant differences among the groups (p 0.02). Ten
patients (24,4%) were treated with intravenous thrombolysis and no
significant differences were found in clinical outcome.
Five of these patients, 50%, therefore, belong to the M1, and even
within this subset there are differences in prognosis.
Conclusion
HMCAS is the most easily accessible predictor of MCA occlusion (1). Hyperdensity sign is related with high stroke severity
and the 3 months unfavourable outcome. In accordance to site of
hyperdensity, proximal tract (M1) is related to the worst prognosis even in patients who received rt-PA treatment. We, therefore,
suggest that patients with M1 tract hyperdensity can be early addressed to alternative procedures such as endovascular treatment
or intra-arterial thrombolysis.
References
T. Kharitonova et al for the SITS Investigator, Hyperdense Middle
Cerebral
Artery Sign on admission CT scan, prognostic significance for
ischemica
stroke patients treated with intravenous thrombolysis in Safe
Implementation of Thrombolysis in Stroke International Stroke
Thrombolysis
Register. Cerbrovasc Dis 2009; 27:51-59.
The Use Of A New Automatic Device For Patients’
Assessment At Triage In Emergency Department
46
Gori Chiara Serena, De Berardinis Benedetta, Salvatori Emiliano, De Nuzzo Daniele, Tranne Caterina, Ferri Enrico,
Di Somma Salvatore
Second Medical School, “Sapienza” University, Sant’Andrea Hospital Emergency Department, Rome, Italy
Objectives.
To assess time saving in an Emergency Department arising out
of the introduction of automatic devices (Carescape™ V100) to
measure vital signs compared to the manual devices.
Methods
We performed a prospective, observational study of eligible patients referring to Sant’Andrea Hospital Emergency Department
during the entire month of October 2009, randomly assigned
into two groups. In the first group of 476 patients vital signs
measurements were detected with manual devices, while in the
second group of 477 patients with automatic device Carescape™
V100.
Results
Data indicated that the comparison of the total time between
the two groups gave a significant difference (1993 vs 1518 min,
p<0,001). No differences were found with respect to age, sex
and priority codes. Significant differences were also found when
comparing the subgroups of the same acuity categories: white codes 4,33 vs 2,27 (min), p<0,05; green codes 4,28 vs 3,37 (min),
p<0,001, yellow codes 3,92 vs 2,72 (min), p<0,001.
Conclusions
Our data demonstrated a statistical significance between the two
groups with a difference of 475 minutes spent in Triage procedures including vital signs measurements. In conclusion time saved
by vital signs automatic device could allow ED physicians to make
a qualified approach with an earlier diagnosis and a more rapid
and effective therapy, possibly improving patients’ outcomes.
Utilità dell’ABCD2 score nel processo decisionale del TIA
in Pronto Soccorso
Efrem Iascone, Augusto Tricerri, Stefania Cerrai, Luigi Zulli
UOC Medicina d’Urgenza e Pronto Soccorso ACO San Filippo Neri, Roma
Introduzione
I pazienti affetti da Attacco Ischemico Transitorio (TIA) costituiscono un gruppo eterogeneo in termini di fattori di rischio,
sintomatologia, comorbidità, prognosi.
L’importanza di riconoscere questa frequente condizione è legata
all’alto rischio di stroke ischemico precoce correlato al TIA (8%
a 30 giorni).
Studi recenti suggeriscono l’utilità dell’ABCD2 score nella stima
del rischio di stroke dopo un TIA. Questo score si basa esclusivamente su parametri clinici di semplice rilevazione (tabella 1),
particolarmente attuabile in quelle circostanze in cui non sia possibile un immediato supporto diagnostico strumentale.
Lo scopo del nostro studio è stato quello di calcolare l’ABCD2
score in una popolazione di pazienti afferita al nostro DEA per
TIA.
Metodi
Sono stati presi in considerazione tutti i pazienti consecutivamente visitati nel periodo gennaio-agosto 2008 presso il DEA del
San Filippo Neri per sospetto TIA e successivamente ricoverati
per osservazione ed approfondimento diagnostico.
Risultati
In 12 pazienti, 8 uomini e 4 donne, la diagnosi di TIA è stata confermata al termine dell’iter diagnostico-osservazionale (tabella 2).
proceedings
Tabella 2 - Risultati preliminari
DONNE
M.S.
TC senza m.d.c.
UOMINI
F.B.
E.N.
E.F.
L.R.
N.M.
A.S.
A.B.
M.V.
R.I.
G.S.
E.G.
F.B.
*
*
*
*
*
*
*
*
*
*
*
*
ECG
*
*
*
*
*
*
*
*
*
*
*
*
*
Ecodoppler TSA
*
*
*
*
*
*
*
*
*
*
*
*
RM encefalo +
DVW
*
*
*
*
Ecocardiogramma
EEG
ABCD2
3
7
*
*
5
*
5
*
*
*
4
*
2
4
*
5
5
*
6
*
4
*
5
3
Conclusioni
Le principali linee guida internazionali raccomandano l’ospedalizzazione dei soli pazienti affetti da TIA con un ABCD2 score
almeno di 3 (American Hearth Association) o di 4 (National In-
stitute of clinical Excellence, UK) e seguire ambulatorialmente
quelli con punteggio inferiore.
La nostra casistica, nonostante il crescente ricorso ad atteggiamenti
clinici di tipo difensivo, si conferma essenzialmente in linea con le
attuali strategie internazionali di sfruttamento delle risorse sanitarie.
Verifying Emergency Room Dyspnea: the VERDI study
V. Russo, B. De Berardinis, F. Travaglino, E. Salvatori, CS. Gori, C. Bongiovanni, V. Mura, O. Piras, S. Di Somma
Emergency department Azienda Ospedaliera Sant’Andrea, II School of Medicine “La Sapienza” Univesity, Rome, Italy
Introduction
Recent literature demonstrated the diagnostic and prognostic role
of several biomarkers in critically ill patients referring to Emergency Department (ED). Patients with acute dyspnea may have
more than one underlying aetiology but ED physician must identify acute and serious life threatening causes.
Recent studies identified biomarkers which increase in patients
with shortness of breath. Procalcitonin (PCT) and Mid Regional
pro- Adrenomedullin (MR pro-ADM) plasma concentration can
increase in several diseases such as bacterial infections, Acute
Myocardial Infarction (AMI), unstable angina, Community Acquired Pneumonia (CAP), Chronic Obstructive Pulmonary Disease (COPD), Acute Respiratory Distress Syndrome (ARDS),
pulmonary hypertension and Systemic Inflammatory Response
Syndrome (SIRS). Mid Regional pro- Atrial Natriuretic Peptide
(MR pro-ANP) is equivalent to BNP (Brain Natriuretic Peptide)
or NT pro BNP (N terminal pro Brain Natriuretic Peptide) in the
diagnosis of Acute Heart failure (AHF) in patients with dyspnea.
The use of a multi - biomarkers panel could be the optimal strategy to promptly diagnose and treat patients with acute dyspnea.
Study design
The study is no profit, competitive, observational, prospective,
multicentric, directed to value diagnostic and prognostic care of
a biomarker’s panel. The enrolment was carried out between June
2009 and June 2010. This study use biomarkers panel (PCT, MR
pro-ANP, MR pro-ADM) to permit accurate and rapids diagnosis of
acute heart failure, pneumonia or sepsis and stratify patient’s risk.
Primary endpoints of the study are:
PCT to value bacterial infections of respiratory tract (differential
diagnosis)
MR pro-ANP to value acute heart failure (differential diagnosis)
Correlation between MR pro-ADM levels and rehospitalisation at
90 days (prognostic value).
Materials and methods
We studied 50 patients admitted to the Emergency Department
with acute dyspnea. All patients were hospitalized. Exclusion criteria: psychogenic dyspnea, post-traumatic dyspnea, cardiogenic
dyspnea, pulmonary embolism, pneumothorax, coronary acute
syndrome, major surgery, burns, haemodialysis treatment, vital
prognosis ‹24 hours, patients transferred, age ‹18 years. The withdrawal was effectuated three times for measurement of plasma
PCT, MR pro-ANP, MR pro-ADM. The first blood sample was obtained on admission to Emergency Department, the second blood sample was obtained after 24 hours; the third blood sample
was obtained after 72 hours. If hospitalization exceeded 72 hours
fourth blood sample was obtained at the discharge. A Case Report
Form was filled up with clinical history, vital signs at the time of
each blood sample. Patients were contacted by phone to evaluate
outcomes 30 and 90 days after discharge.
Conclusions. The study confirmed the PCT value to diagnosis of
bacterial infections, the MR pro-ANP value to diagnosis of acute
heart failure. VERDI study demonstrated that patients with higher levels of MR pro-ADM underwent to rehospitalisation at 90
days.
Periodo di riferimento gennaio-agosto 2008
47
Via Candido Viberti 7 - 10141 Torino - Tel. 011 338 507 - [email protected]
In caso di mancato recapito restituire a: C.M.P. Torino Romoli per la restituzione al mittente previo pagamento resi

I Congresso Nazionale Great Italia, Roma 19

Transcript

Documenti analoghi

080924_cs_balletto_Emergency

SEKUR Moby Tekna

Rischio Oncogeno dei Miomi

N° 02/2014 - Associazione Geriatri Extraospedalieri

“Buskashi”. Lettera alla figlia dall`Afganistan

HUET - EBS - Centro Formazione Offshore

Il paziente giusto, nel posto giusto, al momento giusto

Concentration of elements in serum of patients affected by multiple

Presentazione standard di PowerPoint

PULMONARY EMBOLISM