Frontiers in Emergency Medicine (E-Journal)
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The journey of Italian emergency medicine
Get PDFThe Emergency Medicine school in Italy is relatively young. It was founded in 2008, and the first specialists were trained 5 years later, in 2013. The school was created to give relevance to the role of the emergency doctor and try to obtain highly specialized and trained figures in managing, quickly and effectively, the various situations that can occur in an emergency department. Before the creation of the school, many colleagues believed that anyone could go to work in an emergency room (ER), even without a specific traineeship for that. In reality, the school was created to try to equate the level of training of Italian first aid doctors to the standards of other western countries, in which the school of emergency medicine had already been established. After a somewhat sluggish start, over the years the emergency and urgency medicine (MEU) school has gained its importance and more and more people have enrolled in what is the most adrenaline-filled and varied training school of all. With the neospecialists there has been a gradual filling of the ERs with highly trained figures in the management of various medical emergencies and equipped with various diagnostic-therapeutic skills. Unfortunately, the situation has changed in recent years. In fact, since 2020 our national health system (SSN, Servizio Sanitario Nazionale) has deteriorated significantly in terms of services and quality. Even before the 2020 various critical issues could have been noticed, such as the lack of staff in many departments, the overcrowding of hospitals, the lack of an effective territorial health support system, it is with the COVID-19 epidemic that our public SNN has really started to falter. Italy, as some may already know, was one of the European countries to suffer the most from the pandemic especially due to the large number of elderly people in Italy. Hospitals, and ERs in particular, were always under pressure and those who worked there were subjected to exhausting shifts. Unluckily, among the consequences of the emergency situation there has been an important departure of doctors from the national health system towards either the free profession or even abroad. Needless to say, among the most abandoned departments in recent times, there are the critical area and intensive care departments and the ER. This led to a major health crisis to which a real solution has not yet been found. Almost all Italian ERs are now understaffed and the doctors who work there have to face exhausting working days and take on many responsibilities. Waiting times in most Italian ERs are getting longer and longer, and episodes of physical and verbal aggression carried out by patients against doctors and healthcare staff are now very so much common. Sadly, the prospect of a life of so many sacrifices has led to a slump in enrollment in graduate school of emergency medicine, with more than 60% of the places available each year vacant. Various ERs have closed and others will be closed if the situation does not improve. In this moment, no effective proposals to solve the problem have been presented by the Italian government. However, there are many doctors who claim their rights and who work with passion every day in often difficult environments. More and more demonstrations and protests are being organized which demand an improvement in working conditions, a higher wage in line with European standards, a reduction in working hours and an increase in annual days off. It goes without saying that emergency medicine doctors are at the forefront of all of this. There are those who say that only by improving the working conditions in the Italian ERs could it be possible to recover the Italian public health system from its serious crisis which forces the Italian government to hire doctors from other foreign states and conversely, Italian doctors to emigrate to other countries that guarantee greater attention to the rights of health professionals, that I cannot be agree with those
Prognostic values of urea/lymphocyte and LDH/lymphocyte ratios for predicting mortality in COVID-19 patients
Get PDFObjective: Serum biomarkers are important for accurately predicting clinical outcomes in coronavirus disease 2019 (COVID-19) patients. Although previous studies showed that lymphopenia in patients is related to disease severity, it is unclear how other serum biomarkers improve the prognostic accuracy of lymphopenia. Changes in urea, and lactate dehydrogenase (LDH) were noted to have considerable predictive value in determining the severity of disease in COVID-19 patients. Therefore, the purpose of this study is to determine whether increases in urea, and LDH are linked to worse outcomes in COVID-19 patients and whether the urea/lymphocyte and LDH/lymphocyte ratios improve the prognostic accuracy of lymphopenia. Methods: The data of confirmed COVID-19 patients in our emergency department (ED) between March 2020, and January 2021, were analyzed retrospectively. The area under the curve (AUC) and logistic regression analysis were used to evaluate the discriminative power of the urea/lymphocyte and LDH/lymphocyte ratios in estimating 30-day mortality. Results: The study included 795 confirmed COVID-19 patients admitted to the ED. Twenty-three patients (2.9%) died, and 772 (97.1%) survived in 30 days. The median age of the patients was 51. The number of males (n: 447, 56.2%) was higher than females (n: 348, 43.8%). The ratios of urea/lymphocyte and LDH/lymphocyte were significantly higher in non-survivors (median: 71.21 and 754.1, respectively) compared to survivors (median: 19.51 and 297.42, respectively) (P<0.001). The AUC for 30-day mortality for the urea/lymphocyte and LDH/lymphocyte ratios was 0.864 and 0.840, respectively. Multivariate logistic regression adjustment found the urea/lymphocyte ratio to be an independent and significant predictor of mortality (P=0.007). The optimum cut-off point for the urea/lymphocyte ratio was 28.07, which had a 91.3% sensitivity and a 68.6% specificity. Conclusion: The urea/lymphocyte and LDH/lymphocyte ratios are useful markers that can be evaluated independently to identify high-risk patients and predict the prognosis of COVID-19
The relation between ST-segment resolution and in-hospital mortality after primary percutaneous coronary interventions
Get PDFObjective: The resolution of ST-segment elevation (>50%) indicates successful reperfusion with thrombolytic therapy. The aim of this study is to evaluate the relation of ST-segment resolution post-primary percutaneous cardiac intervention (PCI) with in-hospital mortality and coronary thrombolysis in myocardial infarction (TIMI) blood flow. Methods: This study is a single-centred retrospective study. The study enrolled 100 patients who were referred to the Nasiriya Heart Centre for primary PCI. We measured the ST segment amplitude in the lead with the highest elevation prior to primary PCI and assessed the ST-segment elevation post-primary PCI. The ratio of ST-segment resolution was calculated and considered complete if reaches ≥70% from the initial ST-segment elevation. We assessed the association of ST-segment resolution with in-hospital mortality. Results: Analysis of the electrocardiogram (ECG) showed that 21 patients (21%) had complete ST-segment (≥ 70%) resolution. No significant association was shown between ST-segment resolution and in-hospital mortality. Two out of 21 patients with complete ST-segment resolution died in the hospital and 6 out of 79 patients with incomplete ST-segment resolution died (P=0.77). There is no significant association between ST-segment resolution and coronary TIMI flow grades. In patients with complete ST-segment resolution, 19 patients had TIMI III flow and 2 patients had TIMI II flow. In patients with incomplete ST-segment resolution, 72 patients had TIMI III flow, 6 patients had TIMI II flow; and 1 patient had no-reflow (P=0.84). Conclusion: Complete ST-segment resolution in post-primary PCI settings has no significant association with in-hospital mortality. Absent or incomplete ST-segment resolution is not necessarily an indicator of coronary artery re-occlusion after primary PCI
Correlation of immature/total granulocyte ratio with return of spontaneous circulation and early mortality in nontraumatic out-of-hospital cardiac arrest
Get PDFObjective: Aim of this study was to examine immature granulocyte/total granulocyte (IG/TG) ratio for prediction of return of spontaneous circulation (ROSC) and early mortality in post cardiac arrest survivors. Methods: The study was carried out prospectively between January 2021 and January 2022. Non-traumatic out-of-hospital cardiac arrest (OHCA), over the age of 18 and non-pregnant were included. Patients’ whose IG levels were not studied, with hematological disease and who receiving immunosuppressive therapy were excluded. A palpable pulsation of the main arteries for at least 15 minutes was considered ROSC. Data were compared between the<4 hour and ≥4 hour survival groups and patients with and without ROSC. Results: Total of 254 OHCA patients were included in the study. ROSC was achieved in 84 (33.1%) of these patients and 170 (66.9%) patients were died. There were 28 patients (33.3%) with survival of <4 hours and 56 patients (66.7%) with survival of ≥4 hours in patients with ROSC. The IG count and IG/TG ratio did not differ significantly between the ROSC groups and between the groups separated by survival time (P>0.05).Conclusion: We found no significant differences between subgroups defined according to survival duration. Similarly, no differences found between OHCA patients with and without sustained ROSC
A narrative review of emergency department design strategies to prevent violence against healthcare personnel: an Indian perspective
Get PDFWorkplace violence in hospitals, specifically in emergency departments (ED), has become a growing concern in recent years. This violence can come from patients, their families, or visitors and can take the form of verbal or physical attacks. Preventing violence in EDs can be achieved through design modifications with minimal personnel and infrastructure requirements. Infrastructure design plays a crucial role in reducing the risk of violence. Private lockers should be available at the ED entrance to limit dangerous objects being brought into the department. Furnishings should be fixed to prevent them from being used as weapons, and evacuation should be facilitated through open rows of seating. Positive distractions, such as gardens or natural areas visible through windows, can reduce stress in patients and lower aggression. Ligature points should be eliminated and tamper-resistant items should be provided to reduce dangers in the built environment. The triage desk should be positioned in a secure area with access control and panic buttons available for staff. Hidden exits should be provided in case of violence and emergency exits should open outward and be lockable only from the outside. It seems that preventing violence in EDs requires a combination of management, technology, planning, and physical design. Proper infrastructure design can play a crucial role in reducing the risk of violence, and healthcare professionals, administrators, and architects should be aware of best practices in ED design
Removing a pin from the urethra of a 14-year-old male patient: a case report
Get PDFThe diagnosis and treatment of foreign bodies in the urogenital system are difficult and it’s rare in children; It may also cause secondary injuries. In this article, we present a 14-year-old male patient who was admitted to the emergency outpatient clinic with complaints of difficulty in voiding and dysuria. He was diagnosed with a pin in the urethra and treated using an endoscopic method. He was hospitalised for foreign body removal after he admitted in his anamnesis about insertion a pin into his urethra the day before his complaints started. A pin was seen in the urethra on the urethrocystoscopy, and was successfully removed. Since foreign body in the urogenital system is rare in children, it is necessary to suspect, in order to make the diagnosis. In most cases, endoscopic intervention is sufficient. Psychiatric consultation should be requested for the patients, especially for pediatrics
Probable abdominal compartment syndrome in an 8-month-old child
Get PDFAn 8-month-old, male child was brought to the emergency department (ED) by his parents with difficulty of breathing. The child developed shortness of breath for one day with cough, but he had no fever. According to the parents, they did not notice the abdominal distension. The child was born prematurely at 25 weeks of gestation and stayed in the neonatal intensive care unit (NICU) for 2 months. Otherwise, he was healthy with minor repeated chest infections and bronchiolitis. In triage, his vital signs were as follows: heart rate:180 beats/min; respiratory rate: 35 breaths/min; temperature: 35± C; oxygen saturation: 70%; and his blood pressure was undetected. The child was immediately transferred to the resuscitation room. The primary survey showed that the patient was comatose with a Glasgow coma scale of 3/15, the pupils were brisk with an unstable airway, and there was bilateral diminished air entry. The oxygen saturation did not improve despite assisted ventilation using an Ambu bag. The central and peripheral pulsation was weak with a delayedcapillary refill, and the blood glucose level was 9 mmol/L. The abdomen was hugely distended and rigid with minimal rectal bleeding. The patient was immediately intubated and connected to mechanical ventilation with subsequent rising of his oxygen saturation to 100%. A plain chest X-ray examination followed the patient’s intubation. Intravenous access was obtained followed by administration of normal saline (20 ml/kg) with subsequent elevation of the blood pressure (82/50mmHg) and decrease in heart rate (160 beats/minute). Initial arterial blood gases (ABG) analysis after intubation showed pH: 6.6; PaCO2 >150 mmHg; PaO2: 100 mmHg; HCO3: 10mEq/L; and lactic acid: 9 mg/dL. Therefore, a bolus of sodium bicarbonate was given, intravenously. Ventilator parameters were set at the maximum limits to wash out carbon dioxide. Repeated ABG analysis showed pH: 6.7; PaCO2: 135 mmHg; PaO2: 150 mmHg; HCO3: 17 mEq/L; and lactic acid: 6.5 mg/dL. Immediate bedside abdominal X-ray and ultrasonography were carried out to rule out intussusception. The child remained critically ill and unstable with fluctuating vital signs. Despite high ventilator parameters and gasgastric tube suction, the child showed no improvement in the respiratory parameters. The child was then transferred to the operation theatre for decompression laparotomy, which showed small bowel (ileum) ischemia. After surgical decompression, the respiratory parameters improved, and the ventilatorparameters were set back to normal settings for the patient’s age and weight. Unfortunately, the child remained critically ill. Then, he developed sepsis and multiple systems organ failure and died after 2 days
Identification of prehospital emergency challenges in the COVID-19 pandemic: a systematic review
Get PDFObjective: The prehospital emergency system, as the front line of the health system, has played a very prominent role in the management of the COVID-19 pandemic. Given that identifying the challenges of this area in facing various crises, especially COVID-19, can be a road map for preparing and planning for crisis management in the future, the current study was conducted with the aim of identifying the challenges of prehospital emergency in facing the corona pandemic. Methods: The present systematic review was carried out based on the PRISMA protocol. The search was conducted using the keywords “challenges, obstacles, prehospital emergency and COVID-19” in PubMed, Scopus, and Web of Science databases, and Google Scholar search engine between December 15, 2019 and March 20, 2023. Non-English articles and articles outside the scope of the COVID-19 pandemic were excluded from the study. CASP (critical appraisal skills program), JBI (Joanna Briggs institute) and MMAT (mixed methods appraisal tool) checklists were used to evaluate the quality of the articles. Results: Based on the searches, 12 articles were finally evaluated. Challenges extracted from the analysis of studies were classified into 3 main categories and 7 subcategories including the main categories of “process, structural, and psychological challenges” and the subcategories of “lack of equipment, inappropriate management of human resources, deficiencies in protocols and instructions, weak staff training, occupational burnout, and weak socio-organizational support”. Conclusion: The prehospital emergencies of the countries have faced some challenges after the outbreak of COVID-19, which requires the implementation of adaptive strategies and the efforts of the authorities to solve them to prepare for similar crises. 
Scoring system for mortality prediction of in-hospital COVID-19 patients in resource-limited settings: a single center cohort study during Delta and Omicron waves
Get PDFObjective: Coronavirus Disease 2019 (COVID-19)-related mortality includes several risk variables that are country-specific in nature. The development of a scoring system is necessary regarding the appearance of novel virus variants. The objective of this research is to develop a prognostic score for COVID-19 patients in resource-constrained settings. Methods: This study used a retrospective and prospective cohort design to identify variables that influence COVID-19 patients' in-hospital mortality. The receiver operating characteristic (ROC) curve analysis was utilized to determine the laboratory variables cut-off. Cox regression analysis was undertaken to determine the exact variables influencing the survival of COVID-19 patients. A scoring system was created using the best model based on the Hosmer-Lemeshow test (calibration) and the area under the curve (AUC) (discrimination ability). Results: Based on calibration and discrimination testing, model 2 (immune disorders, unconsciousness, cerebrovascular disease, onset, and oxygen saturation) was rated as the most advantageous model. Model 2 (without age adjustment) had a superior AUC than model 2A (with age). Cut-off was determined at 2, and calculated for onset ≥7 days (AUC=0.816, 95% CI: 0.742,0.890) and <7 days (AUC=0.850, 95% CI: 0.784,0.916). There was no difference in scoring system utilization for subjects recruited during Delta or Omicron waves (P=0.527). Conclusion: The model (cut-off value ≥2) which incorporated age ≥65 years, immune disorders, decreased consciousness, increased respiratory rate, and oxygen saturation <95% is the best model in our study to predict COVID-19 patient mortality
Efficacy and safety of sofosbuvir in the treatment of SARS-CoV-2: an open label phase II trial
Get PDFObjective: Despite the worldwide spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an effective specific antiviral treatment for coronavirus disease of 2019 (COVID-19) is yet to be identified .We did this study to investigate the safety and efficacy of sofosbuvir as antiviral therapy among hospitalized adult patients with SARS-CoV-2. Methods: Patients were randomized into intervention arm receiving sofosbuvir or comparison arm receiving usual antiviral agents in addition to standard of care. The primary end point of the study was clinical recovery as defined by normal body temperature and normal oxygen saturation. The main secondary outcome was all-cause mortality during the admission in hospital or within 14 days after discharge if applicable. Reports of severe adverse events were observed in the intervention arm. Results: Fifty-seven patients enrolled into either the clinical trial arm (n=27) or the comparison arm (n=30). Primary outcome was achieved by 24 (88.9%) and 10 (33.3%) in the intervention and comparison arms, respectively. Median hospital length of stay was significantly shorter in the intervention arm (10 days [IQR: 5-12] vs. 11.5 days [IQR: 8.5-17.75], P = 0.016). All-cause mortality was two and thirteen in intervention and comparison groups, respectively. No serious adverse events were reported by the patients receiving sofosbuvir during the study. Conclusion: Among patients hospitalized with SARS-CoV-2, those who received sofosbuvir had more clinical recovery rate and had a shorter hospital length of stay than those who received usual antiviral agents in the study and these differences were statistically significant