Acute coronary syndrome after initiation of amoxicillin/clavulanate.

We report the case of a 54 year old man referred to the Emergency Department for rapid onset of an itchy rash and oppressive epigastric pain after assumption of amoxicillin/clavulanate. Electrocardiogram aand laboratory findings were consistent with acute coronaty syndrome. After coronary angiography, diagnosis of type II Kounis syndrome was made.

Comment on Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357.

We read the article of Savioli G. et al. [...].

Bleeding prevalence and transfusion requirement in patients with thrombocytopenia in the emergency department.

BACKGROUND: Thrombocytopenia is the most common coagulation disorder in critically ill patients. No studies have investigated the epidemiology and clinical impact of this condition in emergency department (ED) patients. We aimed to investigate epidemiological features, incidence of bleeding, and diagnostic and therapeutic requirements of patients with thrombocytopenia admitted to the ED. METHODS: We performed a retrospective observational study enrolling all patients admitted to the medical-surgical ED of the "Città della Salute e della Scienza di Torino" Hospital with a platelet count <150×10(9) PLTs/L, during four non-consecutive months. There were no exclusion criteria. RESULTS: The study included 1218 patients. The percentage of patients with severe (<50×10(9) PLTs/L) or very severe (<20×10(9) PLTs/L) thrombocytopenia was about 12%. Thrombocytopenia associated with liver cirrhosis was the most represented etiology. On the contrary, the most frequent cause in patients with newly recognized low platelet count was disseminated intravascular coagulation/sepsis. The incidence of bleeding and hypovolemia, as well as the need of transfusional support and mechanical, surgical or endoscopic hemostasis progressively increased with the severity of thrombocytopenia. CONCLUSIONS: Our results suggest that the detection of a platelet count lower than 50×10(9) PLTs/L may help to identify patients with higher bleeding risk in the ED setting. Additional studies are required to evaluate whether, in this setting, thrombocytopenia may represent an independent risk factor for bleeding episodes and increased mortality.

Determinants of inappropriate acute pain management in old people unable to communicate verbally in the emergency department.

OBJECTIVES: Poor pain management is relevant among individuals unable to communicate verbally (UCV). Analgesia may be due to three determinants: patients' status, physician's characteristics and pain etiology. Our aim is to investigate the association between prescription of ED pain treatment and these determinants. MATERIALS AND METHODS: An observational prospective study including UCV patients was conducted. Severity of pain was evaluated by ALGOPLUS Scale and a score P ≥ 2 out of 5 on the pain scale was retained as the threshold for the presence of acute pain in elderly UCV patients. RESULTS: Our data showed that only 31,9% of UCV patients received a pharmacological treatment. The presence of the caregiver would influence the rate of therapy administration [OR 6,19 (95% CI 2,6-14,75)]. The presence of leg pain [OR 0,32 (95% CI 0,12-0,86)] and head pain [OR 0,29 (95% CI 0,10-0,84)] were less likely associated to receive analgesia. Pain related to trauma [OR 4.82 (95% CI 1.17 to 19.78)] and youngest physicians [OR 1.08 (95% CI 1.001 to 1.18)] were variables associated with the administration of drugs opiates. DISCUSSION: Older UCV patients presenting to the ED with pain are at high risk of inadequate analgesia. Providers should always suspect presence of pain and an increasing need for behavioural pain evaluation is necessary for a complete assessment. CONCLUSIONS: Presence of a caregiver influences a more appropriate pain management in these patients. Staff training on pain management could result in better assessment, treatment, and interaction with caregivers.

Hepatic brucelloma.

We present a case of hepatic abscess caused by Brucella melitensis (or hepatic brucelloma) diagnosed in a 59-year-old man 33 years after an episode of acute brucellosis that had completely resolved. Recovery from symptoms and a decrease in lesion size seen on radiological assessment were achieved through prolonged combined antibiotic therapy, without the need for surgery. Hepatic brucelloma is a rare complication of brucellosis, which is the most common zoonosis globally, mainly occurring in specific endemic areas and causing a range of clinical manifestations. In this Grand Round, we review the clinical manifestations, diagnostic approach (through laboratory, radiology, and histology findings), differential diagnosis, treatment, and prognosis of hepatic brucelloma.