Emergency medicine: the Italian experience

BACKGROUND: Studies using tacrolimus and corticosteroids or the combination of cyclosporine, mycophenolate mofetil, and corticosteroids have been shown to reduce the incidence of biopsy-proven acute rejection episodes in cadaveric kidney recipients compared with cyclosporine-based immunosuppression. The current study is a retrospective analysis of our experience with tacrolimus combined with mycophenolate mofetil and steroids as primary immunosuppression for kidney transplant recipients. METHODS: In a retrospective analysis, 72 patients who received primary therapy with tacrolimus, mycophenolate mofetil, and corticosteroids (triple therapy) were compared with a control group of 98 kidney recipients who received tacrolimus and corticosteroids (double therapy). RESULTS: There was a significant reduction in the incidence of biopsy-confirmed acute rejection in the triple therapy group (8.2%) compared with the double therapy group (21%; P=0.003). One-year patient and graft survival did not differ between groups. The incidence of posttransplant diabetes mellitus was 18% and 21% in the triple and double therapy groups, respectively. Leukopenia and gastrointestinal side effects were the most common cause for discontinuation of mycophenolate mofetil. CONCLUSIONS: The combination of tacrolimus with mycophenolate mofetil and corticosteroids is more effective at preventing early acute rejection than tacrolimus and corticosteroids alone. The use of mycophenolate mofetil was associated with a higher incidence of leukopenia and diarrhea, often leading to discontinuation of the drug.     

Emergency cervical cerclage: Ramathibodi Hospital experience

This retrospective study is to evaluate the outcome of pregnancy after emergency cervical cerclage. Records of patients, who were treated with emergency cervical cerclage in Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, from 1982 to 1997, were reviewed. Maternal age, gravida, parity, past obstetric history, gestational age at cerclage, latency period, complication and outcome were noted. Only one of 7 patients who had this operation performed, aborted. The others continued pregnancy and all the babies were born alive. There was no serious maternal complication. This operation has a favorable outcome in selected cases.     

Extrahospital cardiac arrest: the experience of Mestre Emergency Service

BACKGROUND: Out-of-hospital cardiac arrest (AC) is one of the leading causes of death in industrialized countries. AC-related mortality can be reduced by rapid intervention. We report the experience of the emergency medical service (EMS) of Mestre on the management of out-of-hospital AC. METHODS: We analyzed 80 cases of out-of-hospital AC observed consecutively by the EMS of Mestre from February 1996 to September 1997: 72 cases (90.0%) involved cardiac etiology and 8 (10.0%) non-cardiac etiology. The 72 cases involving cardiac etiology were divided in three groups: group A) 12 unwitnessed ACs (16.7%); group B) 12 ACs witnessed by EMS personnel (16.7%); group C) 48 bystander-witnessed ACs (66.6%). RESULTS: In group A, in which 4/12 patients (33.3%) presented ventricular fibrillation (FV) or pulseless ventricular tachycardia (TV) as initial rhythm, return of spontaneous circulation (ROSC) was obtained in one patient with FV and in one patient with asystole. In group B, 7/12 patients (58.3%) presented FV or TV as initial rhythm; in this subgroup, ROSC was obtained in 71.4% of cases (4 cases with FV and one case with TV) and discharge in 42.9%, while in the subgroup with other rhythms the rate of ROSC was 40.0% (two patients with pulseless electrical activity later died). In group C, 35/48 patients (72.9%) presented VF or TV as initial rhythm; in this subgroup, ROSC was achieved in 42.9% of cases (13 cases with FV and 2 cases with TV) and discharge in 14.3%, while in the subgroup of bystander-witnessed AC with other rhythms the rate of ROSC was extremely low (7.7%) (one patient with asystole later discharged). In group C, bystander cardiopulmonary resuscitation (CPR) was performed in 20/48 patients (40.1%). In these patients, FV or TV were more frequently recorded as initial rhythm (80.0 vs 67.9%; p < 0.05). In patients without bystander CPR, the interval between the time of collapse and the time of the first defibrillation was shorter in the patients who were admitted than in patients who died (6.0 +/- 1.4 vs 10.9 +/- 4.4 min; p < 0.05). Considering all patients with FV or TV as initial rhythm and the interval between the collapse and the first defibrillation exactly recorded, the percentage of ROSC decreased when the interval between the collapse and the first defibrillation increased. CONCLUSIONS: Our data confirm that early defibrillation is the key factor in the prognosis of out-of-hospital AC. The data suggest that the immediate delivery of bystander CPR could extend the interval in which defibrillation is effective.     

Mobile Ad Hoc Network-Enabled Collaboration Framework Supporting Civil Engineering Emergency Response Operations

This paper presents an information-technology-based collaboration framework that facilitates disaster response operations. The collaboration framework incorporates a web collaboration service, radio frequency identification (RFID) tags, a building blackbox system (BBS), a geo-database, and a geographic information system (GIS). Through the integration of these technologies, the framework provides a collaboration medium for first responders, including civil engineers, to cohesively respond to disasters. Access to critical building information, such as construction documents, through the BBS supports assessments of building integrity during disaster response. Building assessment information is stored on RFID tags, which are accessible to first responders through digital devices via a wireless ad hoc network. With on-site assessment information shown on a digital map, decision makers locate, collect, and distribute critical resources through the GIS to first responders. In addition, the decision makers at distributed locations evaluate the incident through discussion sessions, hosted by the web collaboration environment, for integrated decision making. Test-bed simulations for the framework have been carried out with encouraging results at the training ground of the Illinois Fire Service Institute.     

Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing

OBJECTIVE: To examine the feasibility of conducting a reverse record-check study to validate parent reporting on child mental health service use and to examine the accuracy of parent reports of child mental health services. METHOD: Information about child service use was abstracted from medical records and subsequently compared with reports provided by caregivers in telephone interviews. A sample of children using outpatient psychiatric services was compared with a sample of children using outpatient orthopaedic services. Rates and correlates of successful caregiver tracking and of service use reporting accuracy were explored. RESULTS: Caregivers of nearly 30% of all index children were contacted and interviewed. Parent reports of lifetime mental health service use were more accurate than reports of lifetime receipt of orthopaedic services. Elapsed time between survey interview and last treatment episode was negatively associated with reporting accuracy. Number of clinic visits was positively associated with reporting accuracy. Preliminary findings suggested that questions about mental health services may be considered sensitive by parents whose children use them. CONCLUSIONS: Reverse record-check studies based on telephone interviews are potentially problematic with a sample drawn from a large, inner-city medical center. Findings suggest that memory difficulties may be a more important correlate of reporting accuracy than response editing (social desirability). Potential discomfort with disclosure of mental health service use does not result in service use underreporting.     

Resuscitation at the roadside

This article summarizes what to do in the event of an emergency outside the dental surgery. It gives a simple and easy to follow guide to preserving life at the roadside when only minimal equipment is available. The fundamental principles of resuscitation will enable the practitioner to save a life in a situation when it is easy to forget the basic techniques in sheer panic. The training of the dental practitioner is an advantage in these uncommon but difficult situations when literally seconds count.     

非常规突发事件特征刻画与应急决策研究

非常规突发事件应急决策是非常规突发事件应急管理的核心.在分析现有突发事件应急决策研究成果的基础上,依据非常规突发事件的内涵和特征刻画,提出基于特征刻画的非常规突发事件应急决策的一系列研究问题,并给出了进一步的研究方向.     

Resuscitation equipment board for nurseries and delivery rooms

A resuscitation equipment board for mounting in delivery rooms and nurseries facilitates orderly and effective resuscitation of asphyxiated neonates.     

Emergency coronary surgery after failed angioplasty: 11 years of experience (1987-1997)

METHODS: From January 1987 to December 1997, thirty patients underwent emergent or urgent coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Dissection/occlusion of the target artery was the commonest complication, but we also had two cases of stent dislocation and one case of coronary artery wall perforation. Two-thirds of the patients experienced extreme preoperatory hemodynamic instability (i.e., cardiac arrest or cardiogenic shock) and half had to be intubated in the Catheterization Laboratory. An average of 1.73 grafts/patient was performed. Complete coronary revascularization was achieved in 93% of the cases; the internal mammary artery could be employed in one-third only. RESULTS: In-hospital mortality was 10%, and perioperatory myocardial infarction or persistent ischemia could be detected in half of the patients. The need for aortic counterpulsation, and the use of inotropic and antiarrhythmic drugs were higher than average in this group of patients; while intensive care unit and hospital stay were longer. Patients with deteriorated preoperative hemodynamics fared significantly worse. Late results were encouraging: seventy-five per cent of all patients (and 84% of hospital survivors) were still alive an average of 52 months after surgery. Two-thirds of all patients (and 72% of hospital survivors) were alive and angina-free. CONCLUSIONS: Even in the current era, revascularization surgery after failed coronary angioplasty still carries an increased risk for postoperative complications and death, especially for patients with deteriorated preoperative hemodynamic conditions. On the other hand, postoperative middle- and long-term results are encouraging, as hospital survivors were similar to elective bypass patients regarding survival and freedom from return of angina.     

Contingent Leadership and Effectiveness of Trauma Resuscitation Teams.

This research investigated leadership and effectiveness of teams operating in a high-velocity environment, specifically trauma resuscitation teams. On the basis of the literature and their own ethnographic work, the authors proposed and tested a contingency model in which the influence of leadership on team effectiveness during trauma resuscitation differs according to the situation. Results indicated that empowering leadership was more effective when trauma severity was low and when team experience was high. Directive leadership was more effective when trauma severity was high or when the team was inexperienced. Findings also suggested that an empowering leader provided more learning opportunities than did a directive leader. The major contribution of this article is the linkage of leadership to team effectiveness, as moderated by relatively specific situational contingencies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute myocardial infarction. Experiences of the referral network of the Beaujon and Bichat hospitals (with the collaboration of the Emergency Medical and Resuscitation Service of Beaujon)

OBJECTIVES: Hospital management of acute myocardial infarction raises many problems in terms of medical care and organization, especially concerning the use or not of emergency corongraphy and angiography. We assessed the pertinence and consequences of a referral network operating between two cardiology units at the Beaujon and Bichat hospitals in Paris. All interventional procedures were performed at the Bichat unit. Prehospital emergency care units were integrated into the exprience and informed of indications for first line coronarography. METHODS: All cases of myocardial infarction admitted within 6 hours to the two units between 1993 to 1996 were analyzed and compared. RESULTS: Indications for referral from Beaujon to Bichat for emergency coronarography and possible angioplasy declined from 21% in 1993 to 10% in 1996. This decline was particularly noteworthy for first intention indications suggesting improved prehospital selection since the number of cases of acute myocardial infarction admitted to Beaujon remained unchanged. Certain patient characteristics differed between the two units: age (68.4 +/- 12.9 years at Beaujon versus 60.5 +/- 13.6 years at Bichat in 1996, p < 0.01) and reperfusion attempts (73% versus 90% in 1996 respectively, p < 0.01). The rate of fatal and non-fatal events were not different: 40 and 40% at Beaujon and 38 and 28% at Bichat in 1993 and 1996 respectively. CONCLUSION: These findings demonstrate that a management network can operate effectively between two hospital cardiology units and emergency care structures, allowing better patient selection for emergency coronography and possible angioplasty.     

Intestinal obstruction. The experience of the Emergency Service of S. José Hospital 1981-1991

The results of 3679 patients, with intestinal obstruction, submitted to emergency surgery at the UUC-HCL between November 1981 and November 1991, were analysed in a general way, with the use of a graphic presentation. In the mechanical group, hernia (1604 cases), adhesions and bands (568 cases) and cancer (713 cases) were the most common pathologies; intestinal ischaemia (143 cases) was the most frequent form in the neurogenic group. Surgical therapy was evaluated in a general way. However, we comment on the evolution of primary surgical treatment of colorectal cancer in obstruction (625 cases). The mortality rate was in general: 10.8% (adults). In relative terms, the main features were intestinal ischaemia (39%), cancer (23%) and intestinal volvulus (22%).     

Emergency fibroendoscopy. Basic exploration in the diagnosis of upper digestive bleeding (experience in 200 cases)

Prognosis in upper gastrointestinal hemorrage (UGIH) depends mostly upon an early diagnosis. The addition of an around the clock endoscopist on duty in the hospital was decided upon to provide inmediate evaluation of all UGIH. The team performed 200 endoscopies, many within the first 12 hours and all of them before 24 hours of bleeding. Endoscopy was unsuccessful in 5 out of 205 attempts. The usefulness of the method was demonstrated as in 94.55% of the patients the cause of the bleeding was established. Peptic ulcers was the cause in 51.5% of the patients and acute inflammatory disease in 14.5%. Esophageal varices were found in 10%, but it is important that we observed 12 patients with non-bleeding varices in which the bleeding was in relation to associated pathologies.     

Advanced life support guidelines. European Resuscitation Council

In order to investigate the relationship between the size of the adenoid and upper respiratory symptoms in children, fibreoptic examination of the nasal cavity and nasopharynx was performed in 817 children. The size of the adenoid was classified into three categories according to the distance between the vomer and the adenoid tissue. There was a significant relation between the size of the adenoid and the complaints of nasal obstruction (P < 0.001) and of snoring (P < 0.001), but not with the presence of purulent sinusitis. In the whole population, the size of the adenoid correlated well with the results of tympanometry (P < 0.001), but this does not hold in all age groups. This study has confirmed adenoid hypertrophy as a common aetiological factor in children with the complaints of nasal obstruction and snoring. The enlargement of the adenoid only partially explains the occurrence of otitis media with effusion. The introduction of the flexible fibrescope in the examination of the nasal cavity and nasopharynx in children is of great clinical value, especially in the selection of children for adenoidectomy. It is a minor invasive examination well tolerated by most children, giving more information than a lateral skull radiograph and avoiding unnecessary radiation.     

Resuscitation measures applied to high surgical-risk urological patients

We study, in the vicinity of Los Angeles International Airport, the effect of jet noise on mental hospital admissions. The maximum noise area (where the maximum fly-over noise exceeds 90 dBA) shows a 29% increase in admissions over those of a corresponding control area, as like the target area as possible, except that in the control area jet noise is not a dominant factor. The results are similar to those of a previous study carried out near Heathrow Airport.     

血管加压素在心肺复苏中的应用进展

探讨血管加压素在心肺复苏中的临床应用新进展。     

Emergency medical services in mass gatherings: the experience of the Formula 1 Grand Prix ''San Marino'' in Imola

Autologous transplantation for non-Hodgkins lymphoma and Hodgkin's disease is widely used as standard therapy for those with high-risk or relapsed tumor. Peripheral blood stem cell (PBSC) collections have nearly completely replaced bone marrow stem cell (BMSC) harvests because of the perceived advantages of more rapid engraftment, less tumor contamination in the inoculum, and better survival after therapy. The advantage of PBSC, however, may derive from the hematopoietic stimulating cytokines used for PBSC mobilization. Therefore, we tested a randomized comparison of GM-CSF vs. G-CSF used to prime either BMSC or PBSC before collection for use in autologous transplantation. Sixty-two patients receiving transplants (31 PBSC; 31 BMSC) for non-Hodgkin's lymphoma (n = 51) or Hodgkin's disease (n = 11) were treated. All patients received 6 days of randomly assigned cytokine. Those with cellular marrow in morphologic remission underwent BMSC harvest, while those with hypocellular marrow or microscopic marrow tumor involvement had PBSC collected. Neutrophil recovery was similarly rapid in all groups (median 14 days; range 10-23 days), though two patients had delayed neutrophil recovery using GM-CSF primed PBSC (p = 0.01). Red cell and platelet recovery were significantly quicker after BMSC mobilized with GM-CSF or PBSC mobilized with G-CSF. This speedier hematologic recovery resulted in earlier hospital discharge as well. However, in multivariate analysis, neither the stem cell source nor randomly assigned G-CSF vs. GM-CSF was independently associated with earlier multilineage hematologic recovery or shorter hospital stay. Relapse-free survival was not independently affected by either the assigned stem cell source or the randomly assigned priming cytokine, though malignant relapse was more frequent in those assigned to PBSC (RR of relapse 3.15, p = 0.03). These data document that BMSC, when collected following cytokine priming, can yield a similarly rapid hematologic recovery and short hospital stay compared with cytokine-primed PBSC. Using primed BMSC, no difference in malignant relapse or relapse-free survival was observed. These findings suggest that despite widespread use of PBSC for transplantation, BMSC, when collected following hematopoietically stimulating cytokines, may remain a satisfactory source of stem cells for autologous transplantation. G-CSF and GM-CSF are both effective in priming autologous PBSC or BMSC for collection.