Iron lung versus conventional mechanical ventilation in acute exacerbation of COPD.

The aim of this randomised study was to compare the effects of iron lung ventilation (ILV) with invasive mechanical ventilation (IMV) in patients with acute respiratory failure (ARF) due to exacerbation of chronic obstructive pulmonary disease. Forty-four patients with ARF were assigned either to ILV (22 patients) or IMV (22 patients). Primary end-points were the improvement in gas exchange and complications related to mechanical ventilation. On admission ILV and IMV groups did not differ in age, simplified acute physiology score II, arterial oxygen tension (Pa,O2)/inspiratory oxygen fraction (FI,O2), arterial carbon dioxide tension (Pa,CO2) and pH. Compared with baseline, ILV and IMV induced a similar and significant improvement in Pa,O2/FI,O2, Pa,CO2 and pH after 1 h of treatment and at discontinuation of mechanical ventilation. Major complications tended to be more frequent in patients treated with IMV than in those treated with ILV (27.3% versus 4.5%), whereas mortality rate was similar (27.3% versus 18.2%). The ventilator-free days and the length of hospital stay were significantly lower in the ILV than in the IMV group. This study suggests that iron lung ventilation is as effective as invasive mechanical ventilation in improving gas exchange in chronic obstructive pulmonary disease patients with acute respiratory failure, and is associated with a tendency towards a lower rate of major complications.

[Appropriateness in the health system: past, present and future]. / L'appropriatezza nel mondo sanitario: passato, presente e futuro.

Nowadays, a health procedure or a clinical pathway are considered appropriate when they appear adequate with respect to scientific knowledge, consistent with the patient's values, safe as to risk management, and convenient with regard to the allocation of resources. This has not always been the case during the course of history, as the different clinical-methodological approaches to the same pathology in different Schools and Universities indicate, even in the same country. A hundred years ago, the difference of approaches could be explained by the limited circulation of ideas, usually based upon weak evidence, if not the personal impressions, of individual physicians. Today, on the contrary, evidence based medicine can represent a useful element in rendering homogeneous different types of behaviour in the same situation, and one of its characterising features is the elaboration of the concept of appropriateness. Appropriateness is a parameter internal to the evolution of health professions, requiring reasoned and shared employment. It originates from the need of health operators to explain why so many different kinds of behaviour exist in the context of the same clinical question. All the issues related to the concepts of clinical judgement and clinical decision-making derive from this and today more and more attention is being dedicated to the idea of appropriateness. The search for appropriateness is a progressive and cyclic process, that may always be improved. At present, strenuous team work is needed to avoid the features of the health system that are more clearly inappropriate, and that emerge from very simple analyses. Doing this is in the interest of the citizens, of health professionals and of the health economy as well.

Implementation of myocardial perfusion imaging in the early triage of patients with suspected acute coronary syndromes.

The risk of overlooking an underlying acute coronary syndrome remains an important challenge in patients complaining of chest pain but who have a non-diagnostic ECG (CP). Indeed, myocardial scintigraphy associated with exercise testing (exercise SPET) represents a valuable tool for excluding coronary artery disease (CAD) especially in patients with CP and delayed presentation to the emergency department. We sought to implement diagnoses of CAD in the early triage of CP patients by exercise gated SPET and compare diagnoses with outcomes. A total of 306 consecutive patients presenting with CP were found to be free of CAD at first line work-up including clinical evaluation, markers of myocardial injury and echocardiogram. These patients were studied initially with exercise SPET, and those with perfusion defects underwent angiography, while those with normal scans were discharged and followed up. Patients with positive scans (34%, n=105) had documented coronary stenoses in 43% (n=45); patients with negative scans (66%, n=201) had evidence of non-fatal coronary events at 6 months in 1.5% (n=3). When imaging was analysed with gating by the presence of transmural perfusion defects associated with wall motion abnormalities (n=86), only one patient, among 19 excluded, was recognized as having coronary stenosis by angiography (SPET vs gated SPET: negative predictive value 98.5% and 98%, respectively, P=NS; diagnostic accuracy 79% and 85%, respectively; P< or =0.03). Therefore, implementation of myocardial perfusion imaging in the early triage of patients with suspected acute coronary syndromes was effectively obtained by early exercise gated SPET, especially in patients with transmural myocardial perfusion defects associated with wall motion abnormalities.

Chest pain unit management of patients at low and not low-risk for coronary artery disease in the emergency department. A 5-year experience in the Florence area.

In this study, we screened a total of 6723 consecutive patients with chest pain and ECG non-diagnostic for acute myocardial infarction (AMI) on presentation to the emergency department (ED). The aim of the study was to avoid missed AMI, improve safe early discharge and reduce inappropriate coronary care unit (CCU) admission. Chest pain patients were triaged using a clinical chest pain score and managed in a chest pain unit (CPU). Patients with a low clinical chest pain score were considered at very 'low-risk' for cardiovascular events and discharged from the ED; patients with a high chest pain score were submitted to CPU management. Observation and titration of serum markers of myocardial injury were obtained up to 6 hours. Rest or stress myocardial scintigraphy (SPECT) was performed in patients > 40 years or with > or = 2 major coronary risk factors. Exercise Tolerance Test (ETT) or Stress-Echocardiogram (stress-Echo) were performed in younger patients or with < 2 coronary risk factor, or unable to exercise, respectively We discharged directly from the ED the majority of patients (4454; 66%): in this group there was only a 0.2% final diagnosis of coronary artery disease (CAD) at follow-up. The remaining 34% of patients, with non-diagnostic or normal ECG, were managed in the CPU. In this group, 1487 patients (representing 22% of the overall study group) were found positive for CAD, two-thirds because of delayed ECG or serum markers of myocardial injury, and one-third by Echo, SPECT or ETT. In conclusion, CPU based management allowed 22% early detection of myocardial ischaemia and 78% early discharge from the ED avoiding inappropriate CCU admission and optimizing the use of urgent angiography.

Early detection of myocardial ischaemia in the emergency department by rest or exercise (99m)Tc tracer myocardial SPET in patients with chest pain and non-diagnostic ECG.

Chest pain (CP) represents a frequent reason for presentation at the emergency department (ED). A large proportion of patients have non-diagnostic ECG on presentation, and in many cases several hours have elapsed since onset of symptoms. Acute rest myocardial scintigraphy (rest SPET) has been shown to have a relevant role in the detection of patients at risk for coronary events, but its sensitivity and negative predictive value are optimal only within the first 3 h following onset of symptoms. In those with delayed presentation, exercise SPET alone, as a screening approach, appears more promising, but its feasibility and diagnostic role in the ED are still unresolved. A total of 231 consecutive patients with a recent-onset (<24 h) first episode of CP had a negative first-line work-up including ECG, troponins, creatine kinase-MB and echocardiography. These patients were considered at low risk for short-term coronary events. Patients were studied with rest SPET if they presented <3 h after onset of CP and exercise SPET if they presented after > or =3 h. The end-points of the study were detection of significant coronary artery disease (CAD) by angiography and major coronary events or cardiac death at 6 months. Eighty patients (35%) underwent rest SPET, while 151 (65%) underwent exercise SPET. Two of the 159 patients with negative SPET had evidence of critical CAD at 6-month follow-up (one patient in the rest SPET group and one in the exercise SPET group; P=NS). Of the 72 patients (31%) with a positive scan, 34 (15%) had documented CAD (16 patients in the rest SPET group and 18 in the exercise SPET group; P=NS). Sensitivity, specificity, accuracy and predictive value were not statistically different between the two groups. In conclusion, the accuracy of exercise SPET in patients with CP and delayed presentation to the ED is comparable to that of validated rest SPET in patients with early presentation. Owing to the high negative predictive value (99%), exercise SPET is especially valuable as a screening tool for the exclusion of CAD in low-risk patients and implementation of early discharge.

Prospective evaluation of adenosine-induced proarrhythmia in the emergency room.

The arrhythmogenic hazard of adenosine treatment in an emergency room (ER) has not been established. Thus, in this study, we set out to prospectively determine the prevalence and clinical consequences of the arrhythmogenic effects associated with urgent adenosine treatment in the ER. One hundred and sixty consecutive patients treated with adenosine for regular wide or narrow complex tachyarrhythmias at our ER were included in the study. An initial bolus of 3 mg of adenosine was used, up to a maximum dose of 18 mg (mode 6 mg). Proarrhythmia was defined as the new appearance of any brady- or tachyarrhythmia within 1 minute from the bolus administration of adenosine. Of the 160 study patients, 84% had narrow complex tachycardia and 16% had wide complex tachycardia. Adenosine was effective in the diagnosis and/or treatment of the underlying arrhythmia in 92%. The overall prevalence of adenosine-induced proarrhythmia was 13%, including prolonged AV block inducing asystole > 4 seconds (7%), paroxysmal atrial fibrillation (1%) and non-sustained ventricular tachycardia (5%). All adenosine-induced arrhythmias were transient and subsided spontaneously. It is concluded, firstly, that adenosine-induced proarrhythmia proved to be frequent in a consecutive ER series, and included potentially dangerous arrhythmias. Secondly, nevertheless, all adenosine-induced arrhythmias subsided spontaneously and did not require treatment. Therefore, urgent adenosine treatment is safe and can be recommended in an emergency setting, provided a strict protocol of administration under close monitoring by highly trained personnel.

[Lyell syndrome and antibiotic therapy]. / Sindrome di Lyell e terapia antibiotica.

Lyell syndrome is an idiosyncratic reaction to drug treatment associated with high mortality due to difficulty in the diagnosis and lack of treatment with proven efficacy. We present the case of a patient treated with antibiotics who developed an exantema-like eruption, diagnosed as Lyell syndrome. The warning signs are represented by a diffuse exantema-like erythema generally associated with fever, large and soft bullae, resembling pemfigo, with subsequent transformation into diffuse erosions following detachment of the epidermis. Skin biopsy is decisive for a correct diagnosis. Negative direct and indirect immunostain, and negative Tzank cytodiagnostic test, associated with histologic findings consistent with "epidermic necrosis with diffuse vacuolar basal stratum degeneration", allow a rapid diagnosis of Lyell syndrome. In our patient, aggressive treatment did not obtain the positive results reported in the literature, possibly due to the advanced stage of the disease.

[Therapeutic infusion of heparin. Application of a nomogram correlated with weight]. / L'infusione terapeutica di eparina. Applicazione di un nomogramma correlato al peso.

We performed a retrospective study to determine whether the use of a nomogram in General Medicine Wards is superior to the empiric method for the adjustment of heparin dosage. In the period october 1998-september 1999 we treated 138 patients with continuous infusion of heparin using a weight-based nomogram. Then we compared these data (nomogram group) with data from period october 1997-september 1998, when we had treated 155 patients with heparin, using empiric method for dose adjustments (empiric group). The proportion of patients reaching the therapeutic aPTT 24 hours after the start of therapy was 90.5% in nomogram group compared with 56.1% in the empiric group (P < 0.001). The proportion of nontherapeutic and subtherapeutic aPTT was significantly reduced in the nomogram group (6.0% vs. 11.1%, P < 0.001; 13.7% vs. 19.3%, P < 0.001). Furthermore, in the nomogram group the proportion of consecutive nontherapeutic or overtherapeutic values were significantly reduced (0.1% vs. 2.2%, P < 0.001; 1.8% vs. 2.3%, P < 0.001). We conclude that a weight-based heparin nomogram adapted for own aPTT range is successfully used in General Medical Wards of a community hospital.

Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction.

BACKGROUND: The role of echocardiographic right ventricular (RV) dysfunction in predicting clinical outcome in clinically stable patients with pulmonary embolism (PE) is undefined. In this study, we assessed the prevalence and clinical outcome of normotensive patients with RV dysfunction among a broad spectrum of PE patients. METHODS AND RESULTS: This prospective clinical outcome study included cohort of 209 consecutive patients (age, 65+/-15 years) with documented PE. Acute RV dysfunction was diagnosed in the presence of >/=1 of the following: RV dilatation (without hypertrophy), paradox septal systolic motion, and Doppler evidence of pulmonary hypertension. Four groups were identified: 28 patients presenting with shock or cardiac arrest (13%), 19 hypotensive patients without shock (9%), 65 normotensive patients with echocardiographic RV dysfunction (31%), and 97 normotensive patients without RV dysfunction (47%). Among normotensive patients with RV dysfunction, 6 (10%) developed PE-related shock after admission: 3 of these patients died, and 3 were successfully treated with thrombolytic agents. In comparison, none of the 97 normotensive patients without RV dysfunction developed shock or died as a result of PE. CONCLUSIONS: A significant proportion (31%) of normotensive patients with acute PE presents with RV dysfunction; these patients with latent hemodynamic impairment have a 10% rate of PE-related shock and 5% in-hospital mortality and may require aggressive therapeutic strategies. Conversely, normotensive patients without echocardiographic RV dysfunction have a benign short-term prognosis. Thus, early detection of echocardiographic RV dysfunction is of major importance in the risk stratification of normotensive patients with acute PE.

Aetiologic diagnosis of ischaemic stroke in the emergency department: relevance for triage and clinical management.

Effective strategies for the aetiologic diagnosis in patients with ischaemic stroke can be implemented based on simple clinical criteria and instrumental tests which can be performed in a modern emergency room (ER) within 24 hours from admission. This may bear prognostic and therapeutic relevance for patients with acute stroke. Therefore, in this study we set out to establish the feasibility and accuracy of the aetiologic diagnosis of ischaemic stroke in an ER. A total of 136 consecutive patients (mean age 72+/-10 years, 60 females) with first ever ischaemic stroke admitted during 1996-1997 were evaluated with assessment of clinical features, CT scan, ECG, ultrasonography of the extracranial arteries, transthoracic echocardiography, and, in selected patients, transoesophageal echocardiography. Patients were classified into two major categories defined as stroke of determined origin and stroke of undetermined origin (a stroke with two or more possible causes or with a negative evaluation), according to the TOAST criteria. Ninety-six patients were considered affected by stroke of determined origin (70.5%), (22.7% with large artery atherosclerosis, 19.1% with cardioembolic stroke, 26.4% with lacunar stroke and 1.4% with other aetiology). The remaining 40 patients (29.4%) had stroke of undetermined origin: of these, 13 patients (9.5%) had a totally negative evaluation, 15 patients (12.5%) showed cardioembolism among the two or more possible causes of stroke and seven patients (5.1%) had atherothrombotic or lacunar aetiology. Additional work-up with transoesophageal echocardiography succeeded in demonstrating aortic embolism in five patients (3.6%; i.e. four patients with aortic plaques more than 4 mm in thickness and one patient with ulcerated plaques). In conclusion, the subtype classification system for ischaemic stroke allowed the aetiological diagnosis in 70.5% of patients while in the ER. Stroke of undetermined origin represented one-third of patients in a consecutive population with acute onset neurologic deficit of ischaemic origin. In approximately half of the patients with negative standard evaluation, cardiogenic or aortic arch embolic sources could be identified by transoesophageal echocardiography. Thus, the latter is indicated in patients with stroke of undetermined origin with negative first-line evaluation in order to identify embolic sources in the aortic arch.

Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism.

The potential role of ultrasound techniques in diagnosing acute pulmonary embolism (PE) has been investigated in severe cases with hemodynamic compromise, but is still unclear for the whole clinical spectrum of patients with suspected PE. The aim of this study was to assess the utility of an integrated bedside evaluation for PE based on the combination of a clinical score, 2-dimensional echocardiography, and color venous duplex scanning. A group of 117 consecutive patients with suspected PE was assessed using a clinical likelihood score, echocardiography, and venous duplex scanning in order to obtain a preliminary diagnosis of PE, which was subsequently compared with the final diagnosis obtained by lung perfusion scintigraphy and angiography. A preliminary diagnosis of PE was made in 70 patients; a final diagnosis of PE was made in 63 patients, of which 56 had and 7 did not have a preliminary diagnosis of PE. The preliminary diagnosis therefore showed 89% sensitivity and 74% specificity, with a total accuracy of 82%. In patients with massive PE, sensitivity and negative predictive values of the preliminary diagnosis were 97% and 98%, respectively. Echocardiography was poorly sensitive (51%) but highly specific (87%) for PE. Thus, the integration of clinical likelihood, echocardiography, and venous duplex scanning provides a practical approach to patients with suspected PE, allows the rapid implementation of appropriate management strategies, and may reduce or postpone the need for further instrumental evaluation of more limited access.

Efficacy and safety of adenosine in diagnosis and treatment of regular tachycardia in the elderly.

BACKGROUND: Adenosine is currently used in the treatment and differential diagnosis of regular tachycardia. However, the efficacy of its employment has not been studied in elderly people. METHODS: We evaluated the safety, and the diagnostic and therapeutic utility of adenosine in elderly people aged over 70 years with regular sustained tachycardia, compared with a group of patients aged under 70 years affected by the same arrhythmia. Adenosine was given to 107 patients in increasing bolus doses up to 18 mg during regular broad and narrow complex tachycardia; 49 patients were aged 70 and over, and 58 patients were aged less than 70 years. In the former group, surface ECG showed 38 narrow complex tachycardias and 11 broad complex ones; in the second group there were 48 narrow complex tachycardias and 10 broad complex ones. RESULTS: Adenosine was effective in 94% of the elderly patients and in 93% of the younger patients. In the group aged over 70 years, adenosine restored sinus rhythm in 37% of patients and revealed the mechanism of arrhythmia in 57%. Adenosine restored sinus rhythm in 50% of patients under 70 years and revealed atrial or sinus tachycardia in 43%. The incidence of symptomatic side effects and peri-conversion ventricular arrhythmias was similar in the two groups. There were ventricular pauses over 3 s long in four (8%) of the older patients (maximum pause 7 s) and in two patients (3%) of the group under 70 years (maximum pause 6 s). No adverse haemodynamic effects were observed. CONCLUSION: These data demonstrate the safety and the value of adenosine in the diagnosis and treatment of regular tachycardia in elderly patients.

[Hyperparathyroidism due to parathyroid carcinoma located in the mediastinum]. / Iperparatiroidismo da carcinoma delle paratiroidi a sede mediastinica.

Parathyroid gland carcinoma is a rare cause of primary hyperparathyroidism. The authors discuss the case of a 56-year-old man who presented with hypercalcemia and multiple bone lesions suggestive of tumor metastases. Laboratory and radiological investigations revealed primary hyperparathyroidism in a patient with evidence of osteitis fibrosa cystica, sustained by carcinoma of a mediastinal parathyroid gland. Early titration of parathyroid hormone (PTH) levels in all patients with hypercalcemia of unclear cause is important for early diagnosis of cases that are tumor-sustained and prevention of the most severe complications. The role of immunostaining with anti-PTH antibodies in demonstrating parathyroid gland tissue in ectopic and/or non-functioning primary tumors, as well as metastases, is also discussed.

Aortofemoral graft infection due to Staphylococcus epidermidis.

A ten-year review of aortofemoral graft infection documented Staphylococcus epidermidis as the infecting organism in 18 (60%) of 30 cases. Diagnosis of such infection required a high index of suspicion because of its late postoperative appearance (mean interval of 41 months) and the inability to identify a microorganism at operation by routine wound culture or Gram's stain. Clinical findings suggesting graft infection included multiple anastomotic aneurysms (18 patients), perigraft exudate (16 patients), a draining groin mass (five patients), and aortoduodenal fistulas (two patients). Due to the low concentration and virulence of the organism, aerobic culture of the prosthetic fabric in broth media provided the optimum method of confirming the S epidermidis infection. Total graft excision with immediate vascular reconstruction was the preferred treatment method and resulted in a mortality and major amputation rate of 11%.

Streptokinase treatment of acute arterial occlusion.

In selected cases, streptokinase, a thrombolytic agent, is an effective alternative to surgical intervention for the treatment of acute arterial occlusions. Successful thrombolysis was achieved in 12 of 16 arterial occlusions (75%) following the intra-arterial infusion of streptokinase at a dosage of 5,000 U per hour. Neither the etiology nor the duration of the occlusions influenced the ability to achieve effective thrombolysis. The major limitation of the technique was the time required to ensure complete thrombolysis (37.5 +/- 17.5 hours). Despite the localized infusion of streptokinase proximal to the arterial obstruction at low dosages, hypofibrinogenemia (100 mg/dl) occurred in five patients and four patients developed a bleeding complication. The use of concomitant heparin (300-500 U per hour) increased the risk of bleeding without increasing thrombolytic potential. Streptokinase treatment of acute arterial occlusions should be used selectively depending on the degree of ischemia, the etiology of the obstruction, and the clinical status of the patient.

Intraoperative pulsed Doppler assessment of carotid endarterectomy.

A 20 MHz pulsed Doppler velocimeter and fast Fourier transform spectrum analyzer were used at operation to assess the velocity patterns just prior to and immediately following carotid endarterectomy (TEA). In all 45 sides studied, the status of the endarterectomized segment was verified by operative arteriography. Corresponding Pre-TEA and Post-TEA internal carotid artery spectra were compared to each other and classified according to criteria developed using the ultrasonic Duplex scanner. Of 39 arteries with significant Pre-TEA flow disturbances, improvement in Post-TEA spectral characteristics was observed in 35, and 4 were not changed. Six arteries had only minimal flow disturbances both before and after endarterectomy. In one case the initial Post-TEA spectrum showed a worsening of the flow disturbance which was found on operative arteriography to be due to a stenosis secondary to a technical error. After vein patch angioplasty, the spectrum and repeat arteriogram were both improved. No other significant technical problems were encountered. Although the velocity patterns were improved by endarterectomy in most cases, some residual flow disturbance often remained. Technical factors were not a major cause of the Post-TEA flow disturbances. Lack of improvement or deterioration in the spectra after closure of the arteriotomy may be useful in selecting patients for operative arteriography. Intraoperative spectra also provide important baseline data for long term followup studies.