Challenges of the next generation hospitals: Rethinking the Emergency Department

The COVID 19 outbreak dramatically highlighted the inadequacy of the Emergency Department (ED) settings in dealing with events that can acutely affect a wide range of population. The immediate urgency to create strictly distinct pathways became also a strategic aspect for reducing possible sources of contagion inside the hospital.1 This need has often clashed with inadequate structural conditions of the hospital: in fact, the rigidity of many EDs is due to the hospital typology and its localization (affected by functional program);2,3 and it prevents them from being quickly adapted to new needs in the case of maxi-emergencies.4 In several recent international projects, the presence of a multifunctional space and/or a buffer area guarantees different scenarios in relation to the healthcare/emergency needs.5 [...]

"Decision tree analysis for assessing the risk of post-traumatic haemorrhage after mild traumatic brain injury in patients on oral anticoagulant therapy"

BACKGROUND

The presence of oral anticoagulant therapy (OAT) alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI). Currently, no specific clinical decision rules are available for OAT patients. The aim of the study was to identify which clinical risk factors easily identifiable at first ED evaluation may be associated with an increased risk of post-traumatic intracranial haemorrhage (ICH) in OAT patients who suffered an MTBI.

METHODS

Three thousand fifty-four patients in OAT with MTBI from four Italian centers were retrospectively considered. A decision tree analysis using the classification and regression tree (CART) method was conducted to evaluate both the pre- and post-traumatic clinical risk factors most associated with the presence of post-traumatic ICH after MTBI and their possible role in determining the patient's risk. The decision tree analysis used all clinical risk factors identified at the first ED evaluation as input predictor variables.

RESULTS

ICH following MTBI was present in 9.5% of patients (290/3054). The CART model created a decision tree using 5 risk factors, post-traumatic amnesia, post-traumatic transitory loss of consciousness, greater trauma dynamic, GCS less than 15, evidence of trauma above the clavicles, capable of stratifying patients into different increasing levels of ICH risk (from 2.5 to 61.4%). The absence of concussion and neurological alteration at admission appears to significantly reduce the possible presence of ICH.

CONCLUSIONS

The machine-learning-based CART model identified distinct prognostic groups of patients with distinct outcomes according to on clinical risk factors. Decision trees can be useful as guidance in patient selection and risk stratification of patients in OAT with MTBI.

Impact of COVID-19 pandemic and lockdown on emergency room access in Northern and Central Italy

In Northern Italy the coronavirus infection has spread since February 2020: the increase in admissions of COVID-19 patients corresponded to a drastic decrease in admissions of regular patients to the Emergency Room (ER). This retrospective study was conducted by Academy of Emergency Medicine and Care (AcEMC). During the lockdown period the accesses were reduced by more than 50%, and in the following months of May and June 2020, there was a recovery clearly below (70%) previous year’s numbers. We have observed a drastic reduction in white and green codes, a fair reduction in yellow codes, while red codes remained stable. The decrease in access to the ER mainly concerned patients with low priority color codes, but also the reduction in the number of accesses of yellow and red codes, insignificant at a superficial glance, is notable. If we consider that yellow and red codes during the months of the lockdown included many patients with COVIDrelated respiratory insufficiency, it is evident that there was a clear reduction in the number of serious illnesses not COVID-related. This is certainly another serious consequence of the COVID-19 pandemic.

Traumatic events involving elderly patients treated with anticoagulants for atrial fibrillation: the downside of stroke prevention

A group of oral anticoagulant-treated patients affected by permanent atrial fibrillation was evaluated after their access to the emergency room as a result of a traumatic accident. In these patients, the re-evaluation of their risk of thromboembolism and bleeding was performed together with the evaluation of their risk of falling and institutionalization. Results show that the emergency department identifies a cohort of very elderly frail patients, who should be carefully reconsidered for anticoagulant therapy after a traumatic event.

Identification of the hydration state in emergency patients: correlation between caval index and BUN/creatinine ratio

BACKGROUND

Dehydration is a frequent clinical problem. No single laboratory value has been found to be accurate; however, the BUN/Creatinine Ratio appears the most sensitive parameter. The respiratory variation (Caval Index, CIn) in the diameter of the inferior vena cava has been investigated as a non-invasive marker for the intravascular volume status.

AIM

The present study is performed with the aim to explore the relationship between CIn and BUN/creatinine ratio.

PATIENTS AND METHODS

This prospective, observational study was conducted at Emergency Department (ED) of San Paolo Hospital (Savona, Italy), in October 2011.

RESULTS

113 patients were considered eligible (mean age of 63 years). We found a good correlation between CIn and BUN/Cr Ratio (Pearson Index 0.76, p < 0.001). Receiver operator characteristic curve (ROC) analyses indicated that the maximum value was 0.884 (p < 0.0001) and corresponded to CIn 60.7%, (sensitivity 79%, specificity 89%). CIn was a good predictor for patients with BUN/Cr ratio greater than 20, and was particularly strong in determining patients with lower BUN/Cr ratio.

DISCUSSION

Our study suggests that inferior vena cava could provide indications on the state of hydration of the patients: we found that a caval index greater than or equal to 60% was associated with a BUN/Cr Ratio over 20, which is considered an important marker for dehydration. Therefore, bedside sonography can give emergency physicians immediate information on patient volume status long before obtaining laboratory findings.

CONCLUSIONS

Our study seems to support the hypothesis that CIn can be a useful bedside marker to predict dehydration in Emergency Department (ED) patients.

[Esophago-gastro-intestinal manometry: study methods and potential clinical applications]

Simultaneous manometry of the esophagus and stomach and/or of the jejunum is an unconventional investigative maneuver that, for the most part, maintains features typical of a physiopathologic inquiry rather than those of clinical testing. This method contemplates the radiologically guided installation of an 8-channel probe, with measuring sites spaced 5 cm one from the other. The proximal measuring site is generally positioned at the lower esophageal sphincter (LES), while the remaining are chosen in order to attain 3 or 4 tips in the stomach and 2 or 3 tips in the duodenum (in the jejunum following stomach resection). The examination lasts approximately 6 hours during digestive rest and 2 hours after administration of a solid test meal. Hence it is possible to evaluate the functional changes at the LES with reference to the phases of the Intestinal Migrating Motor Complex, as well as the possible adverse reactions of poor gastroduodenal motility on the sphincter, both during digestive rest and after a meal. The examination, besides the obvious interest of physiopathological nature, in the Authors' experience, has made it possible to attain quite helpful functional clarifications in identifying the clinical picture of patients with complex esophageal and gastric symptoms, reduced gastric emptying, whether or not associated with mixed reflux in the esophagus. This evaluation was found to be useful both in patients with an "intact" stomach and in those who experienced surgery of the initial portion of the digestive tract.

[Intraoperative manometry during functional surgery of the esophagus]

The purpose of this investigation was to verify the suitability of intra-operative manometry in the course of functional surgery of the esophagus, especially with reference to the results obtained in terms of sphincter functionality, related to the overall changes in symptoms and pH-metry. The practice disclosed herein refers solely to the Heller-Dor operation for esophageal achalasia and to the Nissen Rossetti operation for gastro-esophageal reflux. The promising results obtained using this method to achieve a complete myotomy during Heller's operation, in our opinion testify in favor of its usefulness with this type of surgical procedure. On the contrary, for preparing a fundoplication we feel that method is of orientative value only, since there is no correspondence between the values obtained at the end of the fundoplication and those recorded 18 to 24 months after surgery. The predictive nature of the examination is thus denied.

[Computerized analysis of esophageal manometry]

Computerized analysis of esophageal manometry should consider the following objectives: a) objectivation of data acquisition; b) precision in calculating the various parameters; c) speed of analysis; d) an easy-to-read and promptly understandable graphic display of the manometric data; e) computation of new parameters capable of defining normal and pathologic function. It is with these objectives in mind that we launched our research project. Five normal subjects and 10 patients, of whom 5 presented esophageal achalasia and 5 gastroesophageal reflux disease, underwent computerized esophageal manometry and were evaluated on the basis of both traditional and innovative parameters, of our own inception. Among the various indexes tested, the "Esophageal transport" parameter, calculated as the ratio of momentum (dp*dT) over speed of propagation of the esophageal contractions, gave rise to particular interest. In our opinion, this parameter can be used as an index of the dynamic function of the organ.

[Functional evaluation of gastric and jejunal transplant after esophagectomy]

Increased survival rates after esophagectomy for cancer and the significant development of forms of therapy alternate to surgical treatment, today compel surgeons to devote far more attention to the methods will pursue in reconstructing the alimentary tract after removal of the esophagus. Nine patients with esophago-gastro-plasty and 6 with esophago-jejuno-plasty, after esophagectomy for cancer, experienced a study of esophageal function. The study consisted of extended esophago-gastro-intestinal manometry, performed both while at digestive rest after a semi-solid meal, and of scintigraphy, performed to investigate gastric emptying. 24-hours esophago-gastric pH-metry was also executed, along with basal and stimulated acidity metering in, patients with gastroplasty. The fundamental alterations, from the manometric point of view in esophago-gastro-plasty, are the absence of phase III of the IMMC interdigestively and in the absence of a motor response when ingesting the meal. Scintigraphically this coincides with a fundamental alteration of gastric tubule emptying. On the contrary, in jejunoplasty the jejunal loop retains adequate motility, both during the interdigestive phase and following a meal. Such strikingly diverse motor behavior explains the higher quality of life of patients with jejunoplasty versus patients in whom the stomach is used to substitute for the esophagus.

[Sphincter function after low anterior resection of the rectum]

Until a few years ago, surgical technique and the age-old convictions of oncological radicality rejected very low rectal resections for cancer, particularly as the problem of postoperative incontinence did not exist. Currently, on the other hand, with the advent of mechanical staplers, the surgeon attempts increasingly to reconcile the possibility of using new sphincter-saving techniques with adequate oncological radicality, backed by accurate pre- and intraoperative staging. It is underlined that postoperative assessment of sphincter function in all its aspects, both clinical and instrumental, may be useful for the purpose of clarifying what anatomical structures should really be saved, delegated to retaining sphincter sensitivity and reflexes, so improving the functional results of operations. In addition, the almost rare identification of manifest or latent postoperative incontinence would make it possible to intervene in operated patients, for example by functional reeducation techniques as happens in the relatively recent biofeedback techniques.